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BACKGROUND & AIMS: Photodynamic therapy with porfimer sodium combined with acid suppression (PHOPDT) is used to treat patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). A 5-year phase 3 trial was conducted to determine the extent of squamous overgrowth of BE with HGD after PHOPDT. METHODS: Squamous overgrowth was compared in patients with BE with HGD randomly assigned (2:1) to receive PHOPDT (n=138) or 20 mg omeprazole twice daily (n=70). Patients underwent 4-quadrant jumbo esophageal biopsies every 2 cm throughout the pretreatment length of BE until 4 consecutive quarterly follow-up results were negative for HGD and then biannually up to 5 years or treatment failure. Endoscopies were reviewed by blinded gastroenterology pathologists. RESULTS: Histologic assessment of 33,658 biopsies showed no significant difference (P> .05) in squamous overgrowth between groups when compared per patient (30% vs 33%) or per biopsy (0.5% vs 1.3%), or when the average number of biopsies with squamous overgrowth were compared per patient (0.48 vs 0.66). The highest grade of neoplasia per endoscopy was not found exclusively beneath squamous mucosa in any patient. CONCLUSIONS: No difference was observed in squamous overgrowth between patients given PHOPDT plus omeprazole compared with only omeprazole. Squamous overgrowth did not obscure the most advanced neoplasia in any patient. Treatment of HGD with PHOPDT in patients with BE does not present a long-term risk of failure to detect subsquamous dysplasia or carcinoma.
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Esôfago de Barrett/tratamento farmacológico , Fotoquimioterapia/efeitos adversos , Idoso , Esôfago de Barrett/patologia , Biópsia , Éter de Diematoporfirina/uso terapêutico , Esôfago/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Omeprazol/uso terapêuticoRESUMO
BACKGROUND: Quantitative spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images can be used to provide additional, objective information about tissue state. OBJECTIVE: Our purpose was to validate RF spectral analysis as a method to distinguish between (1) benign and malignant lymph nodes and (2) normal pancreas, chronic pancreatitis, and pancreatic cancer. DESIGN AND SETTING: A prospective validation study of eligible patients was conducted to compare with pilot study RF data. PATIENTS: Forty-three patients underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes (19 from a previous pilot study and 24 additional patients). MAIN OUTCOME MEASUREMENTS: Midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were determined. RESULTS: Discriminant analysis of mean pilot-study parameters was then performed to classify validation-study parameters. For benign versus malignant lymph nodes, midband fit and intercept (both with t test P < .058) provided classification with 67% accuracy and area under the receiver operating curve (AUC) of 0.86. For diseased versus normal pancreas, midband fit and correlation coefficient (both with analysis of variance P < .001) provided 93% accuracy and an AUC of 0.98. For pancreatic cancer versus chronic pancreatitis, the same parameters provided 77% accuracy and an AUC of 0.89. Results improved further when classification was performed with all data. LIMITATIONS: Moderate sample size and spatial averaging inherent to the technique. CONCLUSIONS: This study confirms that mean spectral parameters provide a noninvasive method to quantitatively discriminate benign and malignant lymph nodes as well as normal and diseased pancreas.
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Endossonografia , Linfonodos/diagnóstico por imagem , Pâncreas/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Pancreatite Crônica/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Linfonodos/patologia , Metástase Linfática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Pâncreas/patologia , Estudos ProspectivosRESUMO
BACKGROUND: Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain. OBJECTIVE: Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions. DESIGN: Prospective, paired design. SETTING: Six academic endoscopy centers. PATIENTS: This study involved patients with upper abdominal pain referred for endoscopy. INTERVENTION: All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion. FOLLOW-UP: telephone interviews and chart reviews. MAIN OUTCOME MEASUREMENTS: Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions. RESULTS: A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies. LIMITATIONS: No cost analysis. CONCLUSION: The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.
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Abdome/diagnóstico por imagem , Dor Abdominal/diagnóstico por imagem , Dor Abdominal/etiologia , Endoscopia do Sistema Digestório , Endossonografia , Dor Abdominal/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Endoscópios , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Adulto JovemRESUMO
BACKGROUND & AIMS: Triage of patients with acute upper gastrointestinal hemorrhage (UGIH) has traditionally required urgent upper endoscopy. The aim of this study is to evaluate the use of artificial neural network for nonendoscopic triage. METHODS: A cohort of 387 patients was used to train (n = 194) and internally validate (n = 193) the neural network, which was then externally validated in 200 patients and compared with the clinical and complete Rockall score. Two outcome variables were assessed: major stigmata of recent hemorrhage and need for endoscopic therapy. Patient cohort data from 2 independent tertiary-care medical centers were prospectively collected. Adult patients hospitalized at both sites during the same time period with a primary diagnosis of acute nonvariceal UGIH. RESULTS: In predicting the 2 measured outcomes, sensitivity of neural network was >80%, with high negative predictive values (92-96%) in both cohorts but with lower specificity in the external cohort. Both Rockall scores had adequate sensitivity (>80%) but poor specificity (<40%) at outcome prediction. Comparing areas under receiver operating characteristic curves, the clinical Rockall score was significantly inferior to neural network in both cohorts (=0.65 vs. >/= 0.78), while in the external cohort, neural network performed similarly to the complete Rockall score (>/= 0.78). CONCLUSIONS: In acute nonvariceal UGIH, artificial neural network (nonendoscopic triage) performed as well as the complete Rockall score (endoscopic triage) at predicting stigmata of recent hemorrhage and need for endoscopic therapy, even when tested in an external patient population.
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Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Redes Neurais de Computação , Triagem/métodos , Idoso de 80 Anos ou mais , Estudos de Coortes , Endoscopia , Feminino , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Medição de RiscoRESUMO
Colonic crypt morphological patterns have shown a close correlation with histopathological diagnosis. Imaging technologies such as high-magnification chromoendoscopy and endoscopic optical coherence tomography (OCT) are capable of visualizing crypt morphology in vivo. We have imaged colonic tissue in vitro to simulate high-magnification chromoendoscopy and endoscopic OCT and demonstrate quantification of morphological features of colonic crypts using automated image analysis. 2-D microscopic images with methylene blue staining and correlated 3-D OCT volumes were segmented using marker-based watershed segmentation. 2-D and 3-D crypt morphological features were quantified. The accuracy of segmentation was validated, and measured features are in agreement with known crypt morphology. This work can enable studies to determine the clinical utility of high-magnification chromoendoscopy and endoscopic OCT, as well as studies to evaluate crypt morphology as a biomarker for colonic disease progression.
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Inteligência Artificial , Colo/citologia , Interpretação de Imagem Assistida por Computador/métodos , Imageamento Tridimensional/métodos , Microscopia/métodos , Reconhecimento Automatizado de Padrão/métodos , Tomografia de Coerência Óptica/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Integração de Sistemas , Adulto JovemRESUMO
Barrett's esophagus (BE) and associated adenocarcinoma have emerged as a major health care problem over the last two decades. Because of the widespread use of endoscopy, BE is being recognized increasingly in all Western countries. In clinical trials of endoscopic optical coherence tomography (EOCT), we defined certain image features that appear to be characteristic of precancerous (dysplastic) mucosa: decreased scattering and disorganization in the microscopic morphology. The objective of the present work is to develop computer-aided diagnosis (CAD) algorithms that aid the detection of dysplasia in BE. The image dataset used in the present study was derived from a total of 405 EOCT images (13 patients) that were paired with highly correlated histologic sections of corresponding biopsies. Of these, 106 images were included in the study. The CAD algorithm used was based on a standard texture analysis method (center-symmetric auto-correlation). Using histology as the reference standard, this CAD algorithm had a sensitivity of 82%, specificity of 74%, and accuracy of 83%. CAD has the potential to quantify and standardize the diagnosis of dysplasia and allows high throughput image evaluation for EOCT screening applications. With further refinements, CAD could also improve the accuracy of EOCT identification of dysplasia in BE.
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Adenocarcinoma/diagnóstico , Esôfago de Barrett/diagnóstico , Endoscopia Gastrointestinal/métodos , Neoplasias Esofágicas/diagnóstico , Interpretação de Imagem Assistida por Computador/métodos , Lesões Pré-Cancerosas/diagnóstico , Tomografia de Coerência Óptica/métodos , Adenocarcinoma/etiologia , Algoritmos , Inteligência Artificial , Esôfago de Barrett/complicações , Neoplasias Esofágicas/etiologia , Humanos , Aumento da Imagem/métodos , Imageamento Tridimensional/métodos , Reconhecimento Automatizado de Padrão/métodos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Models based on artificial neural networks (ANN) are useful in predicting outcome of various disorders. There is currently no useful predictive model for risk assessment in acute lower-gastrointestinal haemorrhage. We investigated whether ANN models using information available during triage could predict clinical outcome in patients with this disorder. METHODS: ANN and multiple-logistic-regression (MLR) models were constructed from non-endoscopic data of patients admitted with acute lower-gastrointestinal haemorrhage. The performance of ANN in classifying patients into high-risk and low-risk groups was compared with that of another validated scoring system (BLEED), with the outcome variables recurrent bleeding, death, and therapeutic interventions for control of haemorrhage. The ANN models were trained with data from patients admitted to the primary institution during the first 12 months (n=120) and then internally validated with data from patients admitted to the same institution during the next 6 months (n=70). The ANN models were then externally validated and direct comparison made with MLR in patients admitted to an independent institution in another US state (n=142). FINDINGS: Clinical features were similar for training and validation groups. The predictive accuracy of ANN was significantly better than that of BLEED (predictive accuracy in internal validation group for death 87% vs 21%; for recurrent bleeding 89% vs 41%; and for intervention 96% vs 46%) and similar to MLR. During external validation, ANN performed well in predicting death (97%), recurrent bleeding (93%), and need for intervention (94%), and it was superior to MLR (70%, 73%, and 70%, respectively). INTERPRETATION: ANN can accurately predict the outcome for patients presenting with acute lower-gastrointestinal haemorrhage and may be generally useful for the risk stratification of these patients.
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Hemorragia Gastrointestinal/classificação , Redes Neurais de Computação , Medição de Risco/estatística & dados numéricos , Doença Aguda , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Recidiva , Reprodutibilidade dos Testes , Triagem/estatística & dados numéricosRESUMO
CONTEXT: Conventional colonoscopy is the best available method for detection of colorectal cancer; however, it is invasive and not without risk. Computed tomographic colonography (CTC), also known as virtual colonoscopy, has been reported to be reasonably accurate in the diagnosis of colorectal neoplasia in studies performed at expert centers. OBJECTIVE: To assess the accuracy of CTC in a large number of participants across multiple centers. DESIGN, SETTING, AND PARTICIPANTS: A nonrandomized, evaluator-blinded, noninferiority study design of 615 participants aged 50 years or older who were referred for routine, clinically indicated colonoscopy in 9 major hospital centers between April 17, 2000, and October 3, 2001. The CTC was performed by using multislice scanners immediately before standard colonoscopy; findings at colonoscopy were reported before and after segmental unblinding to the CTC results. MAIN OUTCOME MEASURES: The sensitivity and specificity of CTC and conventional colonoscopy in detecting participants with lesions sized at least 6 mm. Secondary outcomes included detection of all lesions, detection of advanced lesions, possible technical confounders, participant preferences, and evidence for increasing accuracy with experience. RESULTS: A total of 827 lesions were detected in 308 of 600 participants who underwent both procedures; 104 participants had lesions sized at least 6 mm. The sensitivity of CTC for detecting participants with 1 or more lesions sized at least 6 mm was 39.0% (95% confidence interval [CI], 29.6%-48.4%) and for lesions sized at least 10 mm, it was 55.0% (95% CI, 39.9%-70.0%). These results were significantly lower than those for conventional colonoscopy, with sensitivities of 99.0% (95% CI, 97.1%->99.9%) and 100%, respectively. A total of 496 participants were without any lesion sized at least 6 mm. The specificity of CTC and conventional colonoscopy for detecting participants without any lesion sized at least 6 mm was 90.5% (95% CI, 87.9%-93.1%) and 100%, respectively, and without lesions sized at least 10 mm, 96.0% (95% CI, 94.3%-97.6%) and 100%, respectively. Computed tomographic colonography missed 2 of 8 cancers. The accuracy of CTC varied considerably between centers and did not improve as the study progressed. Participants expressed no clear preference for either technique. CONCLUSIONS: Computed tomographic colonography by these methods is not yet ready for widespread clinical application. Techniques and training need to be improved.
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Colonografia Tomográfica Computadorizada , Colonoscopia , Neoplasias Colorretais/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
Barrett's esophagus (BE) and associated adenocarcinoma have emerged as a major health care problem. Endoscopic optical coherence tomography is a microscopic sub-surface imaging technology that has been shown to differentiate tissue layers of the gastrointestinal wall and identify dysplasia in the mucosa, and is proposed as a surveillance tool to aid in management of BE. In this work a computer-aided diagnosis (CAD) system has been demonstrated for classification of dysplasia in Barrett's esophagus using EOCT. The system is composed of four modules: region of interest segmentation, dysplasia-related image feature extraction, feature selection, and site classification and validation. Multiple feature extraction and classification methods were evaluated and the process of developing the CAD system is described in detail. Use of multiple EOCT images to classify a single site was also investigated. A total of 96 EOCT image-biopsy pairs (63 non-dysplastic, 26 low-grade and 7 high-grade dysplastic biopsy sites) from a previously described clinical study were analyzed using the CAD system, yielding an accuracy of 84% for classification of non-dysplastic vs. dysplastic BE tissue. The results motivate continued development of CAD to potentially enable EOCT surveillance of large surface areas of Barrett's mucosa to identify dysplasia.
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This study assessed the ability of spectral analysis of endoscopic ultrasound (EUS) RF signals acquired in humans in vivo to distinguish between (1) benign and malignant intraabdominal and mediastinal lymph nodes and (2) pancreatic cancer, chronic pancreatitis, and normal pancreas. Mean midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were computed over regions of interest defined by the endoscopist. Linear discriminant analysis was then performed to develop a classification of the resulting spectral parameters. For lymph nodes, classification based on the midband fit and intercept provided 67% sensitivity, 82% specificity, and 73% accuracy for malignant vs. benign nodes. For pancreas, classification based on midband fit and correlation coefficient provided 95% sensitivity, 93% specificity, and 93% accuracy for diseased vs. normal pancreas and 85% sensitivity, 71% specificity, and 85% accuracy for pancreatic cancer vs. chronic pancreatitis. These promising results suggest that mean spectral parameters can provide a non-invasive method to quantitatively characterize pancreatic cancer and lymph malignancy in vivo.
Assuntos
Endossonografia/métodos , Linfonodos/diagnóstico por imagem , Linfoma/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Ultrassonografia/métodos , Abdome , Calibragem , Neoplasias do Sistema Digestório/diagnóstico por imagem , Neoplasias do Sistema Digestório/epidemiologia , Neoplasias do Sistema Digestório/mortalidade , Humanos , Pâncreas/diagnóstico por imagem , Imagens de Fantasmas , Valor Preditivo dos Testes , Curva ROC , Sensibilidade e Especificidade , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Controlled trials support pancreatic-stent placement as an effective intervention for the prevention of post-ERCP acute pancreatitis in high-risk patients. OBJECTIVE: To perform a decision analysis to evaluate the most cost-effective strategy for preventing post-ERCP pancreatitis. DESIGN: Cost-effectiveness analysis. SETTING: Patients undergoing ERCP. INTERVENTIONS: Three competing strategies were evaluated in a decision analysis model from a third-party-payer perspective in hypothetical patients undergoing ERCP. In strategy I, none of the patients had pancreatic-stent placement. Strategy II had only those patients identified to be at high risk for post-ERCP, and, in strategy III, all patients underwent prophylactic stent placement. Probabilities of developing post-ERCP pancreatitis and the risk reduction by placement of a pancreatic stent were obtained from published information. Cost estimates were obtained from Medicare reimbursement rates. MAIN OUTCOME MEASUREMENTS: Incremental cost-effectiveness ratio (ICER) of different strategies. RESULTS: Strategy I was the least-expensive strategy but yielded the least number of life years. Strategy II yielded the highest number of years of life, with an ICER of $11,766 per year of life saved, and strategy III was dominated by strategy II. LIMITATIONS: Indirect costs and pharmacologic prophylaxis were not considered in this analysis. CONCLUSIONS: Pancreatic-stent placement for the prevention of post-ERCP pancreatitis in high-risk patients is a cost-effective strategy.
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Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Ductos Pancreáticos/cirurgia , Pancreatite/prevenção & controle , Implantação de Prótese/economia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Tomada de Decisões , Seguimentos , Humanos , Pessoa de Meia-Idade , Método de Monte Carlo , Pancreatite/economia , Pancreatite/etiologia , Prognóstico , Implantação de Prótese/instrumentação , Implantação de Prótese/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Disfunção do Esfíncter da Ampola Hepatopancreática/diagnósticoRESUMO
OBJECTIVE: To prospectively determine if the current practice of radiologists' interpretation of post-ERCP spot images sent by endoscopists resulted in discrepancies in interpretation, affected subsequent management of patients, and resulted in additional costs. METHODS: A prospective analysis of 145 consecutive patients who underwent ERCP over the course of 4 months was performed. A separate endoscopist, not involved in the patient's care, reviewed the radiologist's report of the ERCP x-ray films to determine whether there was either concordance or discordance with the procedural findings. All patients' clinical courses were prospectively followed for a minimum of 6 months to determine whether clinical decision-making was affected by the radiologists' interpretation of the x-ray films. Secondarily, the cost of the current practice of postprocedure interpretation of ECRP radiographs was measured. SETTING: This study took place at University Hospitals of Cleveland, which is a tertiary care facility. RESULTS: In total, there were 61 (47%) discordant interpretations of 130 cholangiograms and 27 (38%) discordant interpretations of 72 pancreatograms, with an overall discordance between an endoscopist and a radiologist in 80 (55%) of the 145 cases. Clinical management was subsequently affected in 3 (2.1%) cases, all of which involved a discordant reading. In each of the 3 cases, further testing validated the gastroenterologist's initial findings at the time of the procedure. Radiologists were reimbursed $5395 for interpretation of ERCP x-ray films. Extrapolated over the course of a year, the reimbursement at this single tertiary care hospital would be greater than $16,000. Additional testing based on discordant reports resulted in $2510 of reimbursement for 3 patients. LIMITATION: The limitation of this study is that it reflects data from only one academic institution. CONCLUSIONS: Radiologists' interpretation of postprocedure ERCP films were inadequate, with a 47% discordance rate among cholangiograms and a 38% discordance rate among pancreatograms. The routine practice of postprocedure ERCP x-ray film interpretation by radiologists altered clinical practice in 2.1% of cases; subsequent care did not confirm radiologists' findings and imparted increased risk to the patients. This practice proved to be a misallocation of resources and should not be continued.
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Doenças Biliares/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica , Pancreatopatias/diagnóstico por imagem , Adulto , Idoso , Doenças Biliares/terapia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Pancreatopatias/terapia , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Stents , Resultado do TratamentoRESUMO
BACKGROUND: EUS is limited by variability in the examiner's subjective interpretation of B-scan images to differentiate among normal, inflammatory, and malignant tissue. By using information otherwise discarded by conventional EUS systems, quantitative spectral analysis of the raw radiofrequency (RF) signals underlying EUS images enables tissue to be characterized more objectively. OBJECTIVE: Our purpose was to determine the feasibility of using spectral analysis of EUS data for characterization of pancreatic tissue and lymph nodes. DESIGN AND SETTING: A pilot study of eligible patients was conducted to analyze the RF data obtained during EUS by using spectral parameters. PATIENTS: Twenty-one subjects who underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes. MAIN OUTCOME MEASUREMENTS: Linear regression parameters of calibrated power spectra of the RF signals were tested to differentiate normal pancreas from chronic pancreatitis and from pancreatic cancer as well as benign from malignant-appearing lymph nodes. RESULTS: The mean intercept, slope, and midband fit of the spectra differed significantly among normal pancreas, adenocarcinoma, and chronic pancreatitis when all were compared with each other (P < .01). On direct comparison, mean midband fit for adenocarcinoma differed significantly from that for chronic pancreatitis (P < .05). For lymph nodes, mean midband fit and intercept differed significantly between benign- and malignant-appearing lymph nodes (P < .01 and P < .05, respectively). LIMITATIONS: Small sample population and spatial averaging inherent to this technique. CONCLUSIONS: Mean spectral parameters in EUS imaging can provide a noninvasive method to discriminate normal from diseased pancreas and lymph nodes.
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Endossonografia , Linfonodos/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico , Projetos Piloto , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Linfonodos/patologia , Metástase Linfática/diagnóstico , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/diagnóstico por imagemRESUMO
BACKGROUND: Barrett's esophagus (BE) with high-grade dysplasia (HGD) is a risk factor for development of esophageal carcinoma. Photodynamic therapy (PDT) with Photofrin (PHO) has been used to eliminate HGD in BE. OBJECTIVE: Our purpose was to compare PHOPDT plus omeprazole with omeprazole only (OM). DESIGN: Five-year follow-up of a randomized, multicenter, multinational, pathology-blinded HGD trial. SETTING: 30 sites in 4 countries. PATIENTS: 208. INTERVENTIONS: Patients with BE and HGD were randomized (2:1) to PHOPDT (n=138) or OM (n=70) into a 2-year trial followed up for 3 more years. PHOPDT patients received 2 mg/kg PHO intravenously followed by endoscopic laser light exposure of Barrett's mucosa at a wavelength of 630 nm within 40 to 50 hours to a maximum of 3 courses at least 90 days apart. Both groups received 20 mg of OM twice daily. Pathologists at one center assessed biopsy specimens in a blinded fashion. MAIN OUTCOME MEASUREMENT: HGD ablation status over 5 years of follow-up. RESULTS: At 5 years PHOPDT was significantly more effective than OM in eliminating HGD (77% [106/138] vs 39% [27/70], P<.0001). A secondary outcome measure preventing progression to cancer showed a significant difference (P=.027) with about half the likelihood of cancer occurring in PHOPDT (21/138 [15%]) compared with OM (20/70 [29%]), with a significantly (P=.004) longer time to progression to cancer favoring PHOPDT. LIMITATIONS: Not all patients were available for follow-up. CONCLUSIONS: This 5-year randomized trial of BE patients with HGD demonstrates that PHOPDT is a clinically and statistically effective therapy in producing long-term ablation of HGD and reducing the potential impact of cancer compared with OM.
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Adenocarcinoma/tratamento farmacológico , Antiulcerosos/uso terapêutico , Esôfago de Barrett/tratamento farmacológico , Neoplasias Esofágicas/tratamento farmacológico , Fotorradiação com Hematoporfirina , Omeprazol/uso terapêutico , Lesões Pré-Cancerosas/tratamento farmacológico , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Esôfago de Barrett/mortalidade , Esôfago de Barrett/patologia , Biópsia , Terapia Combinada , Éter de Diematoporfirina , Progressão da Doença , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Esôfago/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/mortalidade , Lesões Pré-Cancerosas/patologia , Segurança , Método Simples-Cego , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: Gastroesophageal reflux disease is a condition frequently associated with esophagitis and motor abnormalities. Recent evidence suggests that proinflammatory cytokines, such as interleukin (IL)-1beta and IL-6, may be implicated because they reduce esophageal muscle contractility, but these results derive from in vitro or animal models of esophagitis. This study used human esophageal cells and tissues to identify the cellular source of cytokines in human esophagitis investigate whether cytokines can be induced by gastric refluxate, and examine whether esophageal tissue- or cell-derived mediators affect muscle contractility. METHODS: Endoscopic mucosal biopsy specimens were obtained from patients with and without esophagitis, organ-cultured, and undernatants were assessed for cytokine content. The cytokine profile of esophageal epithelial, fibroblast, and muscle cells was analyzed, and esophageal mucosa and cell products were tested in an esophageal circular muscle contraction assay. RESULTS: The mucosa of esophagitis patients produced significantly greater amounts of IL-1beta and IL-6 compared with those of control patients. Cultured esophageal epithelial cells produced IL-6, as did fibroblasts and muscle cells. Epithelial cells exposed to buffered, but not denatured, gastric juice produced IL-6. Undernatants of mucosal biopsy cultures from esophagitis patients reduced esophageal muscle contraction, as did supernatants from esophageal epithelial cell cultures. CONCLUSIONS: The human esophagus produces cytokines capable of reducing contractility of esophageal muscle cells. Exposure to gastric juice is sufficient to stimulate esophageal epithelial cells to produce IL-6, a cytokine able to alter esophageal contractility. These results indicate that classic cytokines are important mediators of the motor disturbances associated with human esophageal inflammation.
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Transtornos da Motilidade Esofágica/imunologia , Transtornos da Motilidade Esofágica/patologia , Refluxo Gastroesofágico/imunologia , Refluxo Gastroesofágico/patologia , Interleucina-1beta/metabolismo , Interleucina-6/metabolismo , Animais , Biópsia , Gatos , Linhagem Celular , Esofagite/imunologia , Esofagite/patologia , Esôfago/citologia , Suco Gástrico , Humanos , Interleucina-1beta/genética , Interleucina-6/genética , Queratinócitos/citologia , Queratinócitos/metabolismo , Mucosa/imunologia , Mucosa/patologia , Contração Muscular , Músculo Liso/fisiologia , Técnicas de Cultura de Órgãos , Reação em Cadeia da Polimerase , RNA Mensageiro/metabolismoRESUMO
BACKGROUND & AIMS: Endoscopic ultrasonography (EUS) staging is used for management of esophageal cancer, but its effect on the outcome of patients is unknown. Our aim was to study the association of receipt of EUS and overall survival in a cohort of patients with esophageal cancer. METHODS: All persons 65 years or older who were diagnosed with esophageal cancer between January 1994 and December 1999 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database were identified. Relevant demographic, cancer-specific information and EUS procedural information were extracted. RESULTS: Two thousand eight hundred thirty patients with esophageal cancer (48% squamous cell cancer) were eligible for analysis. Only 303 (10.7%) patients underwent a EUS examination. Patients who had EUS evaluation were more likely to undergo esophageal resection (21.1% vs 14.7%, P = .01) and more likely to have received adjuvant therapy (11.2% vs 6.7%, P = .008). When adjusted for age at diagnosis, race, gender, comorbidity, histology, and tumor stage, receipt of EUS was associated with a reduced risk of death (relative hazard, 0.594; 95% confidence interval, 0.52-0.68; P = .001). CONCLUSIONS: Undergoing EUS in patients with esophageal cancer is independently associated with improved survival, possibly because of improved stage-appropriate management such as use of adjuvant therapy and surgical resection.
Assuntos
Adenocarcinoma/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Endossonografia , Neoplasias Esofágicas/diagnóstico por imagem , Adenocarcinoma/mortalidade , Idoso , Carcinoma de Células Escamosas/mortalidade , Neoplasias Esofágicas/mortalidade , Feminino , Humanos , Masculino , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: Current guidelines recommend consideration of screening patients with chronic GERD for Barrett's esophagus (BE). Unsedated esophagoscopy (UE) is a less costly alternative to standard EGD for identifying BE. The aim of this study was to determine the indications for EGD referral, the barriers to screening, and the interest in performing UE. METHODS: A one-page survey was mailed to a random sample of 500 family practitioners and 500 internists. This sample was obtained from the American Academy of Family Physicians and American Society of Internal Medicine (500 from each organization). RESULTS: The overall response rate was 54%. The majority (78%) refer more than 50% of their GERD patients for EGD; however, 34% also refer more than 10% of their patients for barium studies. Primary care physicians cited alarm symptoms, refractory symptoms, and chronicity and severity of symptoms as the major indications for referral for EGD. Gender, age, obesity, and tobacco use were cited less frequently. Cost of endoscopy, poor patient acceptance, and lack of evidence were the most common reasons cited for not referring for EGD. A majority of respondents (62%) indicated that the availability of UE would increase referral for the procedure, and 52% would be willing to perform UE in their office. CONCLUSIONS: Severe, refractory, and chronic symptoms are the primary reasons for endoscopic referral from primary care physicians who manage patients with GERD. Other risk factors for BE, such as gender and age, do not appear to be important determinants for endoscopic referral. Further evaluation of UE as a mechanism to increase screening for BE in primary care patients is merited.
Assuntos
Atitude do Pessoal de Saúde , Endoscopia Gastrointestinal , Refluxo Gastroesofágico/diagnóstico , Pesquisas sobre Atenção à Saúde , Médicos de Família , Padrões de Prática Médica/tendências , Sedação Consciente , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/normas , Esofagoscopia/métodos , Feminino , Humanos , Masculino , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Optical coherence tomography (OCT), a noninvasive optical imaging technique, provides high-resolution cross-sectional images of tissue microstructure. We developed a system for real-time endoscopic OCT (EOCT) of the human GI tract. During clinical trials, the structure of mucosa and submucosa, glands, blood vessels, pits, villi, and crypts was observed in a range of GI organs. Although EOCT images are thought to accurately depict actual histologic features, there are few data to support this assumption. Therefore, the present study correlated images acquired with an EOCT imaging system in vitro to corresponding histologic sections. METHODS: EOCT images were obtained of fresh specimens of ileum, colon, and rectum that then were fixed in formalin and were processed for microscopic evaluation by using standard methods. The thickness of mucosa and of submucosa was determined for both EOCT images and histologic slides. RESULTS: The first hyper-reflective layer in the EOCT images was identified as mucosa. A close correlation (R 2=0.84) was observed between EOCT and histology. Furthermore, the submucosa and the muscularis propria could be identified as the next deepest hyporeflective band and a hyper-reflective layer, respectively, in EOCT images. The submucosa was found to be more compressible than mucosa, and its EOCT appearance was dependent on its content of adipose tissue. CONCLUSIONS: EOCT provides images that precisely correlate with the histologic structure of the mucosa and the submucosa of the GI tract.
Assuntos
Colo/patologia , Endoscopia Gastrointestinal/métodos , Íleo/patologia , Processamento de Imagem Assistida por Computador , Reto/patologia , Tomografia de Coerência Óptica/métodos , Humanos , Técnicas In Vitro , Mucosa Intestinal/patologia , Reprodutibilidade dos TestesRESUMO
BACKGROUND: In vivo optical coherence tomography (OCT) imaging has not yet been applied to the pancreatic ductal system. The aim of this study was to obtain in vivo OCT images of dog pancreatic and biliary ducts, and to correlate the images with histology. METHODS: Images of dog pancreatic and biliary ducts were obtained by using an in vivo OCT probe introduced through the respective papillary orifices. Each duct was imaged in multiple locations, and the site of imaging was marked with injected India ink. After imaging, the dogs were euthanized, and the pancreaticobiliary system was harvested. Histologic cross sections were correlated with in vivo OCT images by measuring the structures seen on in vivo OCT images and correlating them with structures seen on corresponding histology slides that contained India ink. OBSERVATIONS: Eighteen pairs of in vivo OCT images and histology slides from the bile duct and the pancreatic duct were obtained from 5 dogs. The entire duct wall could be visualized. A low reflective in vivo OCT layer corresponding to the epithelium could be discerned on many images. The bile duct showed a more complex architecture and had greater variations within the reflective OCT layers, possibly because of greater cellularity within the lamina propria. Nuclei within cells could not be identified, and structures adjacent to the ducts could not be imaged. CONCLUSIONS: In vivo OCT is capable of imaging the pancreaticobiliary ductal system and of identifying the epithelial layer. Because of limited depth of imaging (320-845 micron), OCT is unlikely to serve the purpose of tumor staging.
Assuntos
Ductos Biliares/anatomia & histologia , Ductos Pancreáticos/anatomia & histologia , Tomografia de Coerência Óptica , Animais , CãesRESUMO
BACKGROUND: Lower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists' attitudes toward unsedated screening with an electronic survey. METHODS: A short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically. RESULTS: Two e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barrett's esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures. CONCLUSIONS: Electronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists' attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.