RESUMO
AIM: The management of large non-pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision-making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision-making may therefore result in improved clinical management. METHOD: An official working group of 13 multidisciplinary specialists was appointed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) to develop a minimum dataset on LNPCPs. The literature review used to structure the ACPGBI/BSG guidelines for the management of LNPCPs was used by a steering subcommittee to identify various parameters pertaining to the decision-making processes in the assessment and management of LNPCPs. A modified Delphi consensus process was then used for voting on proposed parameters over multiple voting rounds with at least 80% agreement defined as consensus. The minimum dataset was used in a pilot process to ensure rigidity and usability. RESULTS: A 23-parameter minimum dataset with parameters relating to patient and lesion factors, including six parameters relating to image retrieval, was formulated over four rounds of voting with two pilot processes to test rigidity and usability. CONCLUSION: This paper describes the development of the first reported evidence-based and expert consensus minimum dataset for the management of LNPCPs. It is anticipated that this dataset will allow comprehensive and standardized lesion assessment to improve decision-making in the assessment and management of LNPCPs.
Assuntos
Tomada de Decisão Clínica/métodos , Pólipos do Colo , Cirurgia Colorretal/normas , Consenso , Gastroenterologia/normas , Humanos , Irlanda , Sociedades Médicas , Reino UnidoRESUMO
BACKGROUND AND AIM: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy. METHODS: This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. RESULTS: The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).
Assuntos
Catárticos/administração & dosagem , Colonoscopia/métodos , Laxantes/administração & dosagem , HumanosRESUMO
BACKGROUND AND STUDY AIMS: Radiofrequency ablation (RFA) is safe and effective for the eradication of neoplastic Barrett's esophagus; however, occasionally there is minimal regression after initial circumferential balloon-based RFA (c-RFA). This study aimed to identify predictive factors for a poor response 3 months after c-RFA, and to relate the percentage regression at 3 months to the final treatment outcome. METHODS: We included consecutive patients from 14 centers who underwent c-RFA for high grade dysplasia at worst. Patient and treatment characteristics were registered prospectively. "Poor initial response" was defined as < 50 % regression of the Barrett's esophagus 3 months after c-RFA, graded by two expert endoscopists using endoscopic images. Predictors of initial response were identified through logistic regression analysis. RESULTS: There were 278 patients included (median Barrett's segment C4M6). In poor initial responders (n = 36; 13 %), complete response for neoplasia (CR-neoplasia) was ultimately achieved in 86 % (vs. 98 % in good responders; P < 0.01) and complete response for intestinal metaplasia (CR-IM) in 66 % (vs. 95 %; P < 0.01). Poor responders required 13 months treatment (vs. 7 months; P < 0.01) for a median of four RFA sessions (vs. three; P < 0.01). We identified four independent baseline predictors of poor response: active reflux esophagitis (odds ratio [OR] 37.4; 95 % confidence interval [CI] 3.2 - 433.2); endoscopic resection scar regeneration with Barrett's epithelium (OR 4.7; 95 %CI 1.1 - 20.0); esophageal narrowing pre-RFA (OR 3.9; 95 %CI 1.0 - 15.1); and years of neoplasia pre-RFA (OR 1.2; 95 %CI 1.0 - 1.4). CONCLUSIONS: Patients with a poor initial response to c-RFA have a lower ultimate success rate for CR-neoplasia/CR-IM, require more treatment sessions, and a longer treatment period. A poor initial response to c-RFA occurs more frequently in patients who regenerate their endoscopic resection scar with Barrett's epithelium, and those with ongoing reflux esophagitis, neoplasia in Barrett's esophagus for a longer time, or a narrow esophagus.
Assuntos
Adenocarcinoma/cirurgia , Esôfago de Barrett/cirurgia , Ablação por Cateter , Neoplasias Esofágicas/cirurgia , Lesões Pré-Cancerosas/cirurgia , Adenocarcinoma/patologia , Idoso , Esôfago de Barrett/patologia , Ablação por Cateter/instrumentação , Ablação por Cateter/métodos , Técnicas de Apoio para a Decisão , Neoplasias Esofágicas/patologia , Esofagoscopia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Lesões Pré-Cancerosas/patologia , Estudos Prospectivos , Método Simples-Cego , Resultado do TratamentoRESUMO
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
With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography [ERCP]), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference.
Assuntos
Endoscopia , Assistência Perioperatória , Inibidores da Agregação Plaquetária/administração & dosagem , Perda Sanguínea Cirúrgica/prevenção & controle , Humanos , Hemorragia Pós-Operatória/prevenção & controle , Trombose/prevenção & controleRESUMO
Since the 1960's, endoscopy has revolutionised the practice of gastroenterology. Although initially diagnostic, endoscopy is now playing an increasingly therapeutic role. There are many reasons to believe that therapeutic endoscopy will shape the practice of gastroenterology further in the future. Only a few years ago we relied on low-resolution fibreoptic endoscopes. Nowadays even standard equipment allows the mucosa to be scrutinised in great detail. Dedicated training in endoscopy together with attention to quality indicators such as polyp detection and caecal intubation rates will ensure that fewer early gastrointestinal cancers are missed in the future. Open access endoscopy and screening programs are being introduced in many Western countries which will also lead to more lesions being detected in their early stages. This chapter discusses the main issues surrounding the endoscopic therapy of lower gastrointestinal cancers.
Assuntos
Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/cirurgia , Colonoscopia/efeitos adversos , Humanos , Mucosa Intestinal/cirurgia , Terapias em EstudoRESUMO
As the prognosis of both gastric and colonic cancer remains poor, the challenge is to detect lesions at an early and treatable stage. The benefit of early detection is not only improved survival, but also that patients may be treated with endoscopic mucosal resection, a low-cost, low-morbidity and low-mortality alternative to surgery. In spite of the increasing use of endoscopy in the West, we are not detecting as many early cancers as in Japan. This chapter will discuss the possible reasons for this discrepancy and give a practical guide to 'Japanese endoscopy techniques'. Finally, we have compiled a comprehensive review of the indications, techniques and complications of endoscopic mucosal resection. Throughout the chapter, controversies have been highlighted to give an insight into the limits of our knowledge and stimulate future research.
Assuntos
Neoplasias do Colo/diagnóstico , Neoplasias do Colo/terapia , Colonoscopia/métodos , Gastroscopia/métodos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/terapia , Neoplasias do Colo/epidemiologia , Feminino , Mucosa Gástrica/patologia , Humanos , Mucosa Intestinal/patologia , Japão/epidemiologia , Masculino , Programas de Rastreamento , Vigilância da População , Prognóstico , Sensibilidade e Especificidade , Neoplasias Gástricas/epidemiologia , Taxa de Sobrevida , Resultado do Tratamento , Reino Unido/epidemiologiaAssuntos
Endoscopia/educação , Sexismo/psicologia , Apoio ao Desenvolvimento de Recursos Humanos/estatística & dados numéricos , Adulto , Atitude do Pessoal de Saúde , Currículo/normas , Endoscopia/psicologia , Feminino , Humanos , Liderança , Masculino , Assunção de Riscos , Inquéritos e Questionários , Apoio ao Desenvolvimento de Recursos Humanos/métodos , Engajamento no TrabalhoRESUMO
INTRODUCTION: Endoscopists are now expected to perform polypectomy routinely. Colonic polypectomy varies in difficulty, depending on polyp morphology, size, location and access. The measurement of the degree of difficulty of polypectomy, based on polyp characteristics, has not previously been described. OBJECTIVE: To define the level of difficulty of polypectomy. METHODS: Consensus by nine endoscopists regarding parameters that determine the complexity of a polyp was achieved through the Delphi method. The endoscopists then assigned a polyp complexity level to each possible combination of parameters. A scoring system to measure the difficulty level of a polyp was developed and validated by two different expert endoscopists. RESULTS: Through two Delphi rounds, four factors for determining the complexity of a polypectomy were identified: size (S), morphology (M), site (S) and access (A). A scoring system was established, based on size (1-9 points), morphology (1-3 points), site (1-2 points) and access (1-3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of scores obtained: level I (4-5), level II (6-9), level III (10-12) and level IV (>12). There was a high degree of interrater reliability for the polyp scores (interclass correlation coefficient of 0.93) and levels (κ=0.888). CONCLUSIONS: The scoring system is feasible and reliable. Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. This may allow for more efficient service delivery and referral pathways.
Assuntos
Colonoscopia/métodos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Invasividade Neoplásica/patologia , Biópsia por Agulha , Colonoscopia/efeitos adversos , Humanos , Imuno-Histoquímica , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Estadiamento de Neoplasias , Prognóstico , Medição de Risco , Resultado do TratamentoRESUMO
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, the European Helicobacter Study Group, the European Society of Pathology, and the Sociedade Portuguesa de Endoscopia Digestiva have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach. 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
Gastrite/terapia , Lesões Pré-Cancerosas/patologia , Lesões Pré-Cancerosas/terapia , Neoplasias Gástricas/epidemiologia , Estômago/patologia , Atrofia , Endoscopia Gastrointestinal , Europa (Continente) , Gastrite/diagnóstico , Gastrite/patologia , Humanos , Metaplasia , Portugal , Lesões Pré-Cancerosas/diagnóstico , Fatores de Risco , Sociedades MédicasRESUMO
BACKGROUND AND STUDY AIMS: Japanese endoscopists have devised a classification system based on mucosal crypt patterns which is helpful for distinguishing between hyperplastic polyps, adenomas, and invasive cancers at colonoscopy. The aim of this study was to assess how well the various types of colonic polyp could be distinguished using conventional colonoscopes after spraying with 0.2 % indigo carmine dye. PATIENTS AND METHODS: The endoscopic appearances of all colonic lesions were assessed in 476 unselected patients using normal-resolution, nonmagnifying colonoscopes after spraying with 0.2 % indigo carmine dye. RESULTS: A total of 709 lesions were found in the 476 patients, and histology was available for 673 of these lesions: 187 lesions were found to be non-neoplastic (128 hyperplastic, 2 juvenile, 30 inflammatory, and 27 classified as "others"); 467 lesions were adenomatous; and 19 lesions were carcinomas. Of the 467 adenomas, 377 were tubular, 77 were tubulovillous, 8 were villous and 5 were serrated; 423/467 were correctly identified (sensitivity 91 %). Of the 187 non-neoplastic lesions, 153 were correctly classified (specificity 82 %). A total of 343 of the 377 tubular lesions were correctly identified as tubular adenomas (sensitivity 90 %), and 46 of the 77 tubulovillous lesions were correctly identified. CONCLUSIONS: Standard colonoscopy with dye spraying can be used to differentiate colonic polyps. Magnification is not always necessary to distinguish neoplastic from nonneoplastic colonic lesions. This finding could result in resource savings in colonoscopic screening.
Assuntos
Pólipos do Colo/diagnóstico , Pólipos do Colo/patologia , Colonoscopia/métodos , Corantes , Índigo Carmim/farmacologia , Indóis , Adulto , Idoso , Idoso de 80 Anos ou mais , Corantes/análise , Diagnóstico Diferencial , Feminino , Humanos , Indóis/análise , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND STUDY AIM: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital. PATIENTS AND METHODS: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study. RESULTS: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % ( P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death. CONCLUSIONS: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.
Assuntos
Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Hemorragia Gastrointestinal/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Although some molecular differences between flat-depressed neoplasias (FDNs) and protruding neoplasias (PNs) have been reported, it is uncertain if the BRAF mutations or the status of phosphorylated mitogen-activated protein kinase (p-MAPK) are different between theses two groups. We evaluated the incidence of BRAF and KRAS mutations, high-frequency microsatellite instability (MSI-H), and the immunohistochemical status of p-MAPK in the nonserrated neoplasias (46 FDNs and 57 PNs). BRAF mutations were detected in four FDNs (9%) and none of PNs (P=0.0369 by Fisher's exact test). KRAS mutations were observed in none of FDNs and in 14 PNs (25%; P=0.0002 by Fisher's exact test). MSI-H was detected in seven out of 44 FDNs (16%) and in one out of 52 of PNs (2%) (P=0.022 by Fisher's exact test). Type B and C immunostaining for p-MAPK was observed in 34 out of 46 FDNs (72%), compared with 24 out of 55 PNs (44%; P=0.0022 by chi(2) test). There was no significant difference in the type B and C immunostaining of p-MAPK between FDNs with and without BRAF mutations. BRAF and KRAS mutations are mutually exclusive in the morphological characteristics of colorectal nonserrated neoplasia. Abnormal accumulation of p-MAPK protein is more likely to be implicated in the tumorigenesis of FDNs than of PNs. However, this abnormality in FDNs might occur via the genetic alteration other than BRAF or KRAS mutation.
Assuntos
Adenocarcinoma/genética , Adenocarcinoma/patologia , Neoplasias Colorretais/genética , Neoplasias Colorretais/patologia , Proteínas Quinases Ativadas por Mitógeno/metabolismo , Proteínas Proto-Oncogênicas B-raf/genética , Adenocarcinoma/metabolismo , Neoplasias Colorretais/metabolismo , Feminino , Humanos , Imuno-Histoquímica , Masculino , Repetições de Microssatélites , Mutação , Fosforilação , Proteínas Proto-Oncogênicas/genéticaRESUMO
BACKGROUND AND STUDY AIMS: As sedation with a combination of benzodiazepines and opioids has been associated with an increased risk of serious cardiorespiratory events, it is rarely used in upper gastrointestinal endoscopy. The combination is, however, still commonly used in sedation for colonscopy and endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to determine the benefits and disadvantages of adding pethidine to diazepam (Diazemuls) in the sedation for colonoscopic examinations. PATIENTS AND METHODS: Seventy-one consecutive patients attending for routine colonoscopy were randomized in a double-blind, placebo-controlled manner to sedation with Diazemuls alone or Diazemuls with pethidine. The colonoscopist was at liberty to administrate any dose of Diazemuls considered appropriate for the patient's age and size, following which the patient was given an injection of pethidine 50 mg or a placebo. Both the patient and the endoscopist were blind to whether pethidine or a placebo was used. Adequacy of sedation was assessed and oxygen saturation recorded throughout the procedure. Oxygen was administered if the oxygen saturation fell below 92%. Patient satisfaction with sedation and recall of the procedure was recorded, by questionnaire, one day after examination. RESULTS: A total of 71 patients were entered into the trial. The two groups were similar with respect to age, sex, weight, alcohol intake, and state of health. An average of 18 mg of Diazemuls was given in the pethidine group and 19 mg in the placebo group. There was no statistically significant difference in the level of sedation obtained with the two regimens, although there was a tendency for the combination of Diazemuls with pethidine to give deeper sedation. Three patients were inadequately sedated with Diazemuls alone, requiring the code to be broken for pethidine to be given. Nine colonoscopies had to be abandoned due to patient intolerance in the group receiving Diazemuls, compared to five in the group receiving the combination regimen (p = 0.22). Twice as many patients receiving the combination of Diazemuls with pethidine required oxygen supplementation to maintain oxygen saturation during the procedure. This difference was highly statistically significant (p = 0.008). With the administration of supplemental oxygen, the average drop in oxygenation was similar in both groups. Satisfaction with sedation and recall for the procedure were similar in both groups. CONCLUSIONS: Although the patients had no preference for either regime, there may be an advantage in using the combination of Diazemuls and pethidine, as there was a trend for this combination to be preferred by the colonoscopists. The combination of a benzodiazepine with an opiate should be used with caution, however, as there was a greater requirement for oxygen in the group sedated by Diazemuls and pethidine.
Assuntos
Colonoscopia , Sedação Consciente , Diazepam , Meperidina , Adolescente , Adulto , Idoso , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Diazepam/administração & dosagem , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Masculino , Meperidina/administração & dosagem , Pessoa de Meia-Idade , Consumo de Oxigênio/efeitos dos fármacos , Satisfação do Paciente , Fatores de Risco , Resultado do TratamentoRESUMO
We are now finding more malignancies in their early stages than previously. Attempts to ablate these lesions are difficult and do not provide the histological information required to decide on further treatment. Surgery is difficult to justify, as only a minority of lesions are associated with lymph node metastases and lesions may not become clinically relevant within the lifetime of an elderly patient. Endoscopic mucosal resection allows cancers to be resected at minimal cost, morbidity and mortality. It is also the most reliable investigation when assessing lesions which are suspicious for containing early cancer. After endoscopic removal, histological assessment of depth of penetration and a search for invasion into lymphatics or venules allows the risk of microscopic lymph node metastases to be predicted. The risk of developing metastatic disease can then be balanced against the risks of surgery in view of the patient's age and health.