RESUMO
Endoscopic injections of botulinum toxin in the cardia or distal esophagus have been advocated to treat achalasia and spastic esophageal motility disorders. We conducted a retrospective study to evaluate whether manometric diagnosis using the Chicago classification in high-resolution manometry (HRM) would be predictive of the clinical response. Charts of patients with spastic and hypertensive motility disorders diagnosed with HRM and treated with botulinum toxin were retrospectively reviewed at two centers. HRM recordings were systematically reanalyzed, and a patient's phone survey was conducted. Forty-five patients treated between 2008 and 2013 were included. Most patients had achalasia type 3 (22 cases). Other diagnoses were jackhammer esophagus (8 cases), distal esophageal spasm (7 cases), esophagogastric junction outflow obstruction (5 cases), nutcracker esophagus (1 case), and 2 unclassified cases. Botulinum toxin injections were performed into the cardia only in 9 cases, into the wall of the distal esophagus in 19 cases, and in both locations (cardia and distal esophagus) in 17 cases. No complication occurred in 31 cases. Chest pain was noticed for less than 7 days in 13 cases. One death related to mediastinitis occurred 3 weeks after botulinum toxin injection. Efficacy was assessed in 42 patients: 71% were significantly improved 2 months after botulinum toxin, and 57% remained satisfied for more than 6 months. No clear difference was observed in terms of response according to manometric diagnosis; however, type 3 achalasia previously dilated and with normal integrated relaxation pressure (4s-integrated relaxation pressure < 15 mmHg) had the worst outcome: none of these patients responded to the endoscopic injection of botulinum toxin. Endoscopic injections of botulinum toxin may be effective in some patients with spastic or hypercontractile esophageal motility disorders. The manometric Chicago classification diagnosis does not seem to predict the results. Prospective randomized trials are required to identify patients most likely to benefit from esophageal botulinum toxin treatment.
Assuntos
Inibidores da Liberação da Acetilcolina/administração & dosagem , Toxinas Botulínicas/administração & dosagem , Transtornos da Motilidade Esofágica/tratamento farmacológico , Seleção de Pacientes , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos da Motilidade Esofágica/classificação , Transtornos da Motilidade Esofágica/fisiopatologia , Esofagoscopia/métodos , Esôfago/fisiopatologia , Feminino , Humanos , Injeções/métodos , Masculino , Manometria/métodos , Pessoa de Meia-Idade , Espasticidade Muscular , Valor Preditivo dos Testes , Pressão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: As part of a hospital clinical research program on endoscopic curative treatment for early epithelial neoplastic lesions of the gastrointestinal tract, a new hospital sterile and non-pyrogenic preparation of fructose (5%)-glycerol (10%) was realized. Under pharmaceutical legislation, the provision of this hospital preparation involves of aseptic process validation and achieve a stability study. MATERIALS AND METHODS: After the aseptic process validation with Mediafill Test, the preparation was made under aseptic conditions associated with a sterilizing filtration according to the good practices preparation. Prepared flexible bags (100mL of solution) were stored for one year in a climatic chamber (25±2°C). To assess stability, the physicochemical controls (fructose concentration, glycerol concentration, hydroxy-methyl-5 furfural [5-HMF] concentration, sodium concentration, pH measure, osmolality and sub-visible particles count) and microbiological (bioburden, bacterial endotoxin and sterility) were performed at regular intervals for one year. RESULTS: Neither significant decrease of fructose concentration, glycerol concentration and sodium concentration nor pH, 5-HMF, osmolality variations out of specifications were observed for one year. The sub-visible particles count, the bacterial endotoxin and sterility were in accordance with the European pharmacopoeia attesting limpidity, apyrogenicity and sterility of this injectable preparation. DISCUSSION AND CONCLUSION: The hospital preparation was stable over one year at 25±2°C, ensuring safe administration in humans within the framework of this clinical research.
Assuntos
Frutose/administração & dosagem , Glicerol/administração & dosagem , Carcinoma/tratamento farmacológico , Estabilidade de Medicamentos , Armazenamento de Medicamentos , Endoscopia , Frutose/química , Neoplasias Gastrointestinais/tratamento farmacológico , Glicerol/química , Reprodutibilidade dos Testes , EsterilizaçãoRESUMO
BACKGROUND: Surgery remains the only potential curative therapy for pancreatic cancer, but compromised physiological reserve and comorbidities may deny pancreatic resection from elderly patients. METHODS: The medical records of all patients who underwent pancreatic resection at our institution (2005-2012) were retrospectively reviewed. Postoperative and long-term outcomes were compared between patients with cutoff age of 70 years. RESULTS: A total of 228 (66 %) and 116 (34 %) patients were <70 and ≥70 years, respectively. Elderly group had worse ASA scores (P < 0.0001) with higher rates of invasive malignant pathologies (75 vs. 67 %, P = 0.14), mainly pancreatic ductal adenocarcinoma (58.6 vs. 44.7 %, P = 0.01). The most common type of resection was pancreaticoduodenectomy (PD) (59 %), followed by distal pancreatectomy (19.8 %). Mean hospital stay was comparable. Elderly patients had less grade ≥IIIb postoperative complications (12 vs. 20.1 %; P = 0.04) and higher postoperative mortality rates (12.9 vs. 3.9 %; P = 0.04). In multivariable Cox proportional hazards model for postoperative mortality, age ≥ 70 years (HR, 3.5; 95 % CI, 1.3-9.3), pancreaticoduodenectomy (HR, 12.6; 95 % CI, 1.6-96), and intraoperative blood loss were significant (P = 0.012; P = 0.015, and P = 0.005, respectively). The overall 5-year survival rates for all patients, for patients aged <70 and ≥70 years were 56, 55, and 41 %, respectively (P = 0.003). CONCLUSIONS: Elderly patients are at higher risk of mortality after pancreatic resection than usually reported case series. Nonetheless, elderly patients can undergo pancreatic resection with acceptable 5-year survival results. Our results contribute for a better, informed decision-making for elderly patients and their family.
Assuntos
Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/cirurgia , Comorbidade , Contraindicações , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIMS: Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) in the treatment of benign colonic strictures. PATIENTS AND METHODS: All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4â-â6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence. RESULTS: The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (nâ=â18) or subocclusive symptoms (nâ=â25) due to anastomotic (nâ=â40), post-ischemic (nâ=â2), or post-radiation (nâ=â1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81â%). Migration was observed in 27 patients (63â%). The median duration of stenting was 21 days (95â%CI 17.8â-â35.4 days). Multivariate analysis showed that stents more than 20âmm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53â%), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found. CONCLUSIONS: FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.
Assuntos
Doenças do Colo/terapia , Endoscopia Gastrointestinal , Obstrução Intestinal/terapia , Stents , Idoso , Remoção de Dispositivo , Feminino , Migração de Corpo Estranho , Humanos , Masculino , Metais , Recidiva , Estudos Retrospectivos , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
Numerous scientific publications explore the field of gastrointestinal (GI) endoscopy (a Pubmed search currently yields > 73000 results). Therefore, guidelines have become an indispensable tool for incorporating up-to-date knowledge into daily clinical care. Since the 1990 s, the issuing of guidelines has been a central task of the European Society of Gastrointestinal Endoscopy (ESGE). Here, the ESGE clarifies the types of policy documents that it issues and the methodology used to produce them, taking into account recent methodological developments.
Assuntos
Endoscopia Gastrointestinal/normas , Medicina Baseada em Evidências , Políticas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Consenso , Coleta de Dados , Europa (Continente) , Humanos , Revisão por ParesRESUMO
BACKGROUND AND AIMS: Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis. METHODS: Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline. SUMMARY OF SELECTED RECOMMENDATIONS: For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Colangiopancreatografia Retrógrada Endoscópica/normas , Gastroenterologia , Pancreatite Crônica/cirurgia , Guias de Prática Clínica como Assunto , Sociedades Médicas , Europa (Continente) , HumanosRESUMO
Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.
Assuntos
Mucosa Gástrica/patologia , Gastrite Atrófica/patologia , Gastrite Atrófica/terapia , Lesões Pré-Cancerosas/patologia , Lesões Pré-Cancerosas/terapia , Neoplasias Gástricas/patologia , Biópsia , Medicina Baseada em Evidências , Gastrite Atrófica/diagnóstico , Gastroscopia , Infecções por Helicobacter/tratamento farmacológico , Infecções por Helicobacter/economia , Infecções por Helicobacter/microbiologia , Helicobacter pylori , Humanos , Metaplasia/patologia , Metaplasia/terapia , Pepsinogênios/sangue , Vigilância da População , Lesões Pré-Cancerosas/diagnósticoRESUMO
PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.
Assuntos
Endoscopia por Cápsula/normas , Endoscopia por Cápsula/métodos , Catárticos/administração & dosagem , Neoplasias do Colo/diagnóstico , Pólipos do Colo/diagnóstico , Contraindicações , Enema , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Prontuários Médicos/normas , Educação de Pacientes como AssuntoRESUMO
OBJECTIVE: Reports on the accuracy of computed tomographic colonography (CTC) mainly involve series from expert institutions. The aims of this study were to assess CTC accuracy in a nationwide population and to relate it to radiologist performance in their initial training. DESIGN: Nationwide multicentre trial. SETTING: Twenty-eight radiologists, working in 26 mostly academic clinical units, were involved in the study after having attended a formal specialised 2-day training session on CTC. They worked through a training set of 52 cases with automatic feedback after an attempt at each case. PATIENTS: The study enrolled 845 patients with average and high risk of colorectal cancer, 737 of whom had both complete CTC and videocolonoscopy data, which constituted the dataset. INTERVENTIONS: Patients underwent same-day CTC followed by videocolonoscopy with segmental unblinding of CTC results. MAIN OUTCOME MEASURES: Sensitivity, specificity and positive and negative predictive values for detection of polyps ≥ 6 mm in per-patient and per-lesion analyses of CTC without computer-aided detection. RESULTS: Sensitivity, specificity and positive and negative predictive values for patients with polyps ≥ 6 mm were 69% (95% CI 61% to 77%), 91% (95% CI 89% to 94%), 67% (95% CI 59% to 74%) and 92% (95% CI 90% to 94%), respectively. Univariate analysis showed that the detection rate for polyps ≥ 6 mm was linked to neither radiologist case volume nor number of polyps, but was related to sensitivity achieved in the training set. Pooled sensitivity was 72% (95% CI 63% to 80%) versus 51% (95% CI 40% to 60%) for radiologists achieving above and below median sensitivity in the training set (61%), respectively. Multivariate analysis showed that sensitivity for polyps ≥ 6 mm in the training set was the only remaining significant predictive factor for subsequent performance. CONCLUSIONS: Radiologist sensitivity CTC for detection of polyps ≥ 6 mm in training was the sole independent predictor for subsequent sensitivity in detection of such polyps.
Assuntos
Competência Clínica , Colonografia Tomográfica Computadorizada/normas , Neoplasias Colorretais/diagnóstico por imagem , Radiologia/normas , Idoso , Pólipos do Colo/diagnóstico , Pólipos do Colo/diagnóstico por imagem , Pólipos do Colo/patologia , Colonografia Tomográfica Computadorizada/métodos , Colonoscopia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/patologia , Educação Médica Continuada/métodos , Métodos Epidemiológicos , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Sangue Oculto , Radiologia/educação , Gravação em VídeoRESUMO
BACKGROUND: Colorectal cancer (CRC) is a major cause of morbidity and mortality in France. Only scanty data on cost-effectiveness of CRC screening in Europe are available, generating uncertainty over its efficiency. Although immunochemical fecal tests (FIT) and guaiac-based fecal occult blood tests (g-FOBT) have been shown to be cost-effective in France, cost-effectiveness of endoscopic screening has not yet been addressed. METHODS: Cost-effectiveness of screening strategies using colonoscopy, flexible sigmoidoscopy, second-generation colon capsule endoscopy (CCE), FIT and g-FOBT were compared using a Markov model. A 40â% adherence rate was assumed for all strategies. Colonoscopy costs included anesthesiologist assistance. Incremental cost-effectiveness ratios (ICERs) were calculated. Probabilistic and value-of-information analyses were used to estimate the expected benefit of future research. A third-payer perspective was adopted. RESULTS: In the reference case analysis, FIT repeated every year was the most cost-effective strategy, with an ICER of 48165 per life-year gained vs. FIT every 2 years, which was the next most cost-effective strategy. Although CCE every 5 years was as effective as FIT 1-year, it was not a cost-effective alternative. Colonoscopy repeated every 10 years was substantially more costly, and slightly less effective than FIT 1-year. When projecting the model outputs onto the French population, the least (g-FOBT 2-years) and most (FIT 1-year) effective strategies reduced the absolute number of annual CRC deaths from 16037 to 12916 and 11217, respectively, resulting in an annual additional cost of 26 million and 347 million, respectively. Probabilistic sensitivity analysis demonstrated that FIT 1-year was the optimal choice in 20% of the simulated scenarios, whereas sigmoidoscopy 5-years, colonoscopy, and FIT 2-years were the optimal choices in 40%, 26%, and 14%, respectively. CONCLUSIONS: A screening program based on FIT 1-year appeared to be the most cost-effective approach for CRC screening in France. However, a substantial uncertainty over this choice is still present.
Assuntos
Endoscopia por Cápsula/economia , Colonoscopia/economia , Neoplasias Colorretais/prevenção & controle , Programas de Rastreamento/economia , Sangue Oculto , Sigmoidoscopia/economia , Simulação por Computador , Análise Custo-Benefício , França , Humanos , Cadeias de MarkovRESUMO
BACKGROUND AND STUDY AIMS: Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France. METHODS: Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up). RESULTS: A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal. CONCLUSION: Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.
Assuntos
Ductos Biliares/patologia , Colecistectomia/efeitos adversos , Constrição Patológica/etiologia , Constrição Patológica/terapia , Stents , Cateterismo , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica/efeitos adversos , Constrição Patológica/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIMS: Covered self-expanding metal stents (SEMSs) have proven effective for managing malignant bile duct strictures and may reduce risk of tumor ingrowth. A new nitinol partially covered biliary SEMS was prospectively evaluated. PATIENTS AND METHODS: 70 patients with inoperable extrahepatic biliary obstructions were enrolled in a prospective multicenter trial, and followed up to 6 months or death, whichever came first. Primary endpoint was adequate palliation defined as absence of recurrent biliary obstruction from partly covered SEMS placement to end of follow-up. RESULTS: Mean age of the patients was 69 years and 52 % were men. Pancreatic carcinoma was present in 68 %. One stent was placed in 67 patients, two patients received two, and in one patient a guide wire could not traverse the stricture. In 55 % of patients the SEMS was inserted de novo and in 45 % for exchange with a plastic stent. Technical success was 97 %. At 6 months, 62 % of patients were free of obstructive symptoms; compared with baseline the mean number of symptoms per patient was significantly reduced (3.1 at baseline, 0.6 at 6 months; P < 0.0001) and total bilirubin levels dropped by 73 %. There were four cases of recurrent biliary obstruction, due to stent migration (2), tumor overgrowth (1), and sludge formation (1). Device-related complications included cholecystitis (3), right upper quadrant pain (1), and moderate pancreatitis (1). No tumor ingrowth was reported. CONCLUSIONS: This new partially covered nitinol SEMS is easily inserted, and safe and effective in the palliation of biliary obstruction secondary to malignant bile duct strictures.
Assuntos
Neoplasias dos Ductos Biliares/complicações , Colestase Extra-Hepática/cirurgia , Materiais Revestidos Biocompatíveis , Cuidados Paliativos , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Ligas , Neoplasias dos Ductos Biliares/secundário , Colestase Extra-Hepática/etiologia , Doenças do Ducto Colédoco/etiologia , Doenças do Ducto Colédoco/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Stents/efeitos adversosRESUMO
BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a technique for "en bloc" resection of superficial tumors of the gastrointestinal tract. In France, experience with this technique is still limited. We wanted to assess the development of ESD in France, with special attention to short term outcomes. PATIENTS AND METHODS: Members of the Société Française d'Endoscopie Digestive (SFED) who declared performing ESD reported their cases prospectively on a voluntary basis. Demographic, clinical, and technical data, and the results of immediate complications were collected. Case reports were completed prospectively by each investigator before pooled analysis. RESULTS: A total of 188 consecutive case reports were collected from 16 centers. The median case mix per center was 6 patients (range 1-43). The lesion sites treated by ESD were the stomach (n = 75), esophagus (n = 27), duodenum (n = 1), cecum (n = 2), right colon (n = 3), transverse colon (n = 5), sigmoid (n = 3), and rectum (n = 72). The median size of the lesions was 26 mm (range 2-150 mm). En bloc resection was achieved in 77.1% of cases, with complete R0 resection in 72.9%. Histopathology results showed high grade dysplasia or superficial cancer in 71.2%. The median duration of ESD was 105 minutes (range 20-450 minutes). The short term morbidity was 29.2% including 34 cases of perforation (18.1%), and 21 hemorrhages (11.2%) during the 24 hours following ESD, 89% of which were managed conservatively or endoscopically. CONCLUSION: In this early experience, the feasibility of ESD appeared to be good but R0 resection and complication rates did not match those reported by Japanese authors and must be improved by an extended practice.
Assuntos
Dissecação/métodos , Endoscopia Gastrointestinal/métodos , Mucosa Gástrica/cirurgia , Neoplasias Gastrointestinais/cirurgia , Mucosa Intestinal/cirurgia , Perfuração Intestinal/etiologia , Hemorragia Pós-Operatória/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Dissecação/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Feminino , França , Neoplasias Gastrointestinais/patologia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Experience in Europe, however, is still limited and ESD is only performed in a few selected centers, with low volumes of cases, no description of training programs, and few published reports. In 2008, a panel of experts gathered in Rotterdam to discuss indications, training, and the wider use of ESD. The panel of experts and participants reached a consensus on five general statements: 1) ESD aims at treating mucosal cancer; 2) treatment aims for R0 resection; 3) ESD should meet quality standards; 4) ESD should be performed following national or European Society of Gastrointestinal Endoscopy (ESGE) guidelines or under institutional review board approval; and 5) ESD cases should be registered. Due to the high level of expertise needed to perform the technique safely, ESD should be performed in a step-up approach, starting with lesions presenting in the rectum or in the distal stomach, then colon, proximal stomach, and finally in the esophagus. Registration is advised either at the local site or at a national or ESGE level, and should include information on indication (Paris classification of lesion, location, and histological results prior to treatment), technique used (e.âg. type of knife), results (en bloc and R0 resection), complications, and follow-up. The panel also agreed on minimal institutional requirements: good quality imaging, experienced histopathologist following the Japanese criteria (2-mm sections, micrometric invasion, vessel and lymphatic infiltration, etc), and dedicated endoscopic follow-up. Moreover, minimum training requirements were also defined: knowledge in indications and instruments, exposure to experts (currently all in Japan), hands-on experience in a model of isolated pig stomach and in live pigs, and management of complications. The experts did not reach a consensus on a minimum case load, or whether the technique should be restricted to expert centers.
Assuntos
Dissecação/métodos , Endoscopia/métodos , Endoscopia/normas , Mucosa Gástrica/cirurgia , Mucosa Intestinal/cirurgia , Dissecação/normas , Educação Médica Continuada , Europa (Continente) , Humanos , Guias de Prática Clínica como Assunto , Controle de Qualidade , Sistema de RegistrosRESUMO
BACKGROUND AND STUDY AIMS: Distinguishing pancreatic adenocarcinoma from other pancreatic masses remains challenging with current imaging techniques. This prospective study aimed to evaluate the accuracy of a new procedure, imaging the microcirculation pattern of the pancreas by contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) with a new Olympus prototype echo endoscope. PATIENTS AND METHODS: 35 patients presenting with solid pancreatic lesions were prospectively enrolled. All patients had conventional B mode and power Doppler EUS. After an intravenous bolus injection of 2.4 ml of a second-generation ultrasound contrast agent (SonoVue) CEH-EUS was then performed with a new Olympus prototype echo endoscope (xGF-UCT 180). The microvascular pattern was compared with the final diagnosis based on the pathological examination of specimens from surgery or EUS-guided fine-needle aspiration (EUS-FNA) or on follow-up for at least 12 months. RESULTS: The final diagnoses were: 18 adenocarcinomas, 9 neuroendocrine tumors, 7 chronic pancreatitis, and 1 stromal tumor. Power Doppler failed to display microcirculation, whereas harmonic imaging demonstrated it in all cases. Out of 18 lesions with a hypointense signal on CEH-EUS, 16 were adenocarcinomas. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of hypointensity for diagnosing pancreatic adenocarcinoma were 89 %, 88 %, 88 %, 89 %, and 88.5 %, compared with corresponding values of 72 %, 100 %, 77 %, 100 %, and 86 % for EUS-FNA. Of five adenocarcinomas with false-negative results at EUS-FNA, four had a hypointense echo signal at CEH-EUS. CONCLUSIONS: CEH-EUS with the new Olympus prototype device successfully visualizes the microvascular pattern in pancreatic solid lesions, and may be useful for distinguishing adenocarcinomas from other pancreatic masses.
Assuntos
Carcinoma Ductal Pancreático/diagnóstico por imagem , Endossonografia/métodos , Pâncreas/diagnóstico por imagem , Pancreatopatias/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/cirurgia , Meios de Contraste , Feminino , Humanos , Masculino , Microcirculação , Pessoa de Meia-Idade , Tumores Neuroendócrinos/diagnóstico por imagem , Tumores Neuroendócrinos/cirurgia , Pâncreas/irrigação sanguínea , Pâncreas/patologia , Pancreatopatias/patologia , Pancreatopatias/cirurgia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Projetos Piloto , Estudos ProspectivosRESUMO
BACKGROUND AND STUDY AIM: Studies on endoscopic mucosal resection (EMR) are mostly based on data from centers with high expertise. We report the average EMR results in a national survey of consecutive patients in France. METHODS: A 1-year survey was carried out to record immediate outcome data of all EMRs performed, regardless of lesion size or gastrointestinal location. RESULTS: Overall, 1335 EMRs in 1210 patients were reported by 241 of the 736 gastroenterologists who performed such procedures (33â%). Resections were done for upper gastrointestinal lesions in 125 cases (41 esophageal, 43 gastric, and 41 duodenal lesions), in 45â% of cases using specific EMR techniques such as ligation, cap, or traction. The technique for resecting the 1210 lower gastrointestinal lesions mostly consisted of saline-assisted polypectomy or EMR, with specific techniques used in only 2.2â%. En bloc resection was less common with esophageal (46â%) or duodenal (54â%) neoplasms than in the lower gastrointestinal tract (73â%); size also had some influence (53â% > 1 cm vs. 92â% ≤ 1 cm). The overall complication rate was 5.2â%; the rate was lower for lesions 1 cm or smaller (0.6â% vs. 4.6â%). Fifty-four early and 17 delayed complications were recorded, in 12â% of upper gastrointestinal and 4.6â% of colonic lesions. Surgery became necessary in 1.6â% for upper and 2.9â% for lower gastrointestinal neoplasms. No association was seen between physician EMR caseload and either en bloc resection rate or complication rate. CONCLUSIONS: EMR in general, especially saline-assisted polypectomy in the colon, appears to be reasonably safe even when performed by nonexperts. EMR for larger or for upper gastrointestinal lesions should probably be limited to high-volume centers.
Assuntos
Carcinoma/cirurgia , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/métodos , Mucosa Gástrica/cirurgia , Neoplasias Gastrointestinais/cirurgia , Mucosa Intestinal/cirurgia , Idoso , Carcinoma/patologia , Dissecação/métodos , Feminino , França , Mucosa Gástrica/patologia , Gastroenterologia , Neoplasias Gastrointestinais/patologia , Humanos , Mucosa Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIM: A video capsule similar to that used in small-bowel capsule endoscopy is now available for esophageal exploration. The aim of our study was to compare the accuracy of upper endoscopy (esophageal gastroduodenoscopy [EGE]) with esophageal capsule endoscopy (ECE) in patients at risk of esophageal squamous cell cancer (SCC). PATIENTS AND METHODS: 68 patients at risk of SCC secondary to a history of head and neck neoplasia were included in this comparison of techniques for detecting SCC and dysplasia. ECE was done using the first generation Pillcam ESO and EGE was performed in accordance with the usual practice of each center, followed by examination with 2 % Lugol staining and biopsy of unstained areas (39 neoplasia comprising 5 low grade dysplasia, 8 high grade dysplasia and 26 SCC). RESULTS: Compared with EGE with and without Lugol staining, the sensitivities of ECE for neoplasia diagnosis were 46 % and 54 %, respectively. On a per-patient basis, the sensitivity, specificity, and positive and negative predictive value of ECE were 63 %, 86 %, 77 % and 76 %, respectively, compared with EGE without staining, and 61 %, 86 %, 77 % and 73 % compared with EGE with iodine staining. Neither the ECE transit time nor the distance between the esopharyngeal line and the neoplastic lesion differed between the 21 false-negative and 18 true-positive cases diagnosed by ECE; the only difference was a smaller median diameter among false negatives ( P < 0.001). CONCLUSION: In a cohort at high risk for esophageal SCC, ECE is not sensitive enough to diagnose neoplastic lesions.
Assuntos
Endoscopia por Cápsula/métodos , Carcinoma de Células Escamosas/diagnóstico , Endoscopia Gastrointestinal/métodos , Neoplasias Esofágicas/diagnóstico , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: Esophagogastroduodenoscopy (EGD) is the standard method for the diagnosis of esophago-gastric varices. The aim of this prospective multicenter study was to evaluate the PillCam esophageal capsule endoscopy (ECE) for this indication. METHODS: Patients presenting with cirrhotic or noncirrhotic portal hypertension underwent ECEfollowed by EGD at the time of diagnosis. Capsule recordings were blindly read by two endoscopists. RESULTS: A total of 120 patients (72 males, mean age: 58 years; mean Child-Pugh score: 7.2) were included. Esophageal varices were detected in 74 patients. No adverse event was observed after either EGD or ECE. Seven (6%) patients were unable to swallow the capsule. The mean recording time was 204 s (range 1-876). Sensitivity, specificity, negative predictive value, and positive predictive value of ECE for the detection of esophageal varices were 77%, 86%, 69%, and 90%, respectively. Sensitivity, specificity, negative and positive predictive values of ECE for the indication of primary prophylaxis (esophageal varices > or = grade 2 and/or red signs) were 77, 88, 90, and 75%, respectively, and 85% of the patients were adequately classified for the indication (or not) of prophylaxis. Interobserver concordance for ECE readings was 79.4% for the diagnosis of varices, 66.4% for the grading of varices, and 89.7% for the indication of prophylaxis. CONCLUSIONS: This large multicenter study confirms the safety and acceptable accuracy of ECE for the evaluation of esophageal varices. ECE might be proposed as an alternative to EGD for the screening of portal hypertension, especially in patients unable or unwilling to undergo EGD.
Assuntos
Endoscopia por Cápsula/métodos , Endoscopia do Sistema Digestório/métodos , Varizes Esofágicas e Gástricas/diagnóstico , Hipertensão Portal/diagnóstico , Adulto , Idoso , Varizes Esofágicas e Gástricas/etiologia , Estudos de Viabilidade , Feminino , Humanos , Hipertensão Portal/complicações , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Satisfação do Paciente , Probabilidade , Estudos Prospectivos , Medição de Risco , Segurança , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Método Simples-CegoRESUMO
OBJECTIVE: To evaluate the impact of a multifaceted interventional program on the compliance of hepatogastroenterologists with guidelines for Barrett's esophagus. DESIGN: In both 2002 and 2005, anonymous postal surveys were sent out, involving eight criteria pertaining to three main areas to assess compliance, to 245 hepatogastroenterologists based in private and public hospitals, and in the community, in a specific region of France. The multifaceted intervention was based on reminders, conferences, postal campaigns and esophageal mapping. Main outcome measures were based on biopsies for diagnosis, surveillance intervals and management of patients with high-grade dysplasia. RESULTS: In 2002 and 2005, survey response rates were 81.6 and 73.9%, respectively. In terms of diagnosis, compliance with the systematic performance of biopsies increased from 26.5 to 59.9% (p<0.01) and, with follow-up, from 41.0 to 52.0%, respectively (p<0.02). Management of high-grade dysplasia increased from 16.0 to 24.3% (p<0.01). Total compliance (with all criteria) was achieved by 5.0% of hepatogastroenterologists in 2002 and by 10.7% in 2005 (p<0.01). CONCLUSION: The present study suggests that a multifaceted interventional program can dramatically improve physician compliance with the guidelines for Barrett's esophagus. For this reason, we recommend that national scientific societies disseminate their guidelines through targeted activity to ensure that they are followed by hepatogastroenterologists.