RESUMEN
Emergency upper gastrointestinal endoscopy in a 45 years old man with a complicated medical history obtained a small ulcer in the gastric corpus bedded in a round impression of 4 cm in diameter and no active bleeding during investigation. We decided to perform an immediate angio-CT-examination of thorax and abdomen. Gastric ulcer and impression were induced by a partially thrombosed aneurysm of the splenic artery. Emergency angiography with percutaneous transluminal implantation of a covered stent into the splenic artery completely bridged the aneurysm. The patient resolved and left the hospital after 12 days. Literature review shows that currently an immediate switch from endoscopy to vascular surgery is the best option in such cases. Emergency endoscopists have to identify the so called herald lesion as what it is and to initiate further diagnostic steps at once, since the second bleeding is mostly fatal. This may increase the prognosis significantly to 20-90 % survival. Unfortunately, in a current survey 50 % of gastroenterologists felt themselves not good informed about this fact and would probably not have done the correct decisions.
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Aneurisma , Úlcera , Humanos , Persona de Mediana EdadRESUMEN
OBJECTIVES: Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. DESIGNS: Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. RESULTS: A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. CONCLUSIONS: This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients. TRIAL REGISTRATION NUMBER: DRKS00007768; Pre-results.
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Sedación Consciente/efectos adversos , Endoscopía Gastrointestinal/efectos adversos , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Sedación Consciente/mortalidad , Endoscopía Gastrointestinal/métodos , Endoscopía Gastrointestinal/mortalidad , Endoscopía Gastrointestinal/estadística & datos numéricos , Femenino , Alemania/epidemiología , Humanos , Hipnóticos y Sedantes/efectos adversos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Propofol/efectos adversos , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND & AIMS: Barrett's esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC. METHODS: We collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barrett's esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis. RESULTS: After a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barrett's esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively. CONCLUSIONS: Endoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.
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Adenocarcinoma/cirugía , Endoscopía/efectos adversos , Endoscopía/métodos , Neoplasias Esofágicas/cirugía , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Anciano , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Esófago/patología , Esófago/cirugía , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Membrana Mucosa/patología , Recurrencia Local de Neoplasia/epidemiología , Estudios Prospectivos , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Colonoscopy is a widely used diagnostic and therapeutic modality. A large proportion of the population is likely to undergo colonoscopy for diagnosis and treatment of colorectal diseases, or when participating in colorectal cancer screening programs. To reduce pain, water infusion instead of traditional air insufflation during the insertion phase of the colonoscopy has been proposed, thereby improving patients' acceptance of the procedure. Moreover, the water infusion method may improve early detection of precancerous neoplasms. OBJECTIVES: To compare water infusion techniques with standard air insufflation, specifically evaluating technical quality and screening efficacy, as well as patients' acceptance of the water infusion procedure. SEARCH METHODS: We searched the Cochrane Colorectal Cancer Group Specialized Register (February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to February 2014), Ovid EMBASE (1974 to February 2014), and ClinicalTrials.gov (1999 to February 2014) for eligible randomised controlled trials. SELECTION CRITERIA: We included randomised controlled trials comparing water infusion (water exchange or water immersion methods) against standard air insufflation during the insertion phase of the colonoscopy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion and extracted data from eligible studies. We performed analysis using Review Manager software (RevMan 5). MAIN RESULTS: We included 16 randomised controlled trials consisting of 2933 colonoscopies. Primary outcome measures were cecal intubation rate and adenoma detection; secondary outcomes were time needed to reach the cecum, pain experienced by participants during the procedure, completion of cecal intubation without sedation/analgesia, and adverse events. Completeness of colonoscopy, that is cecal intubation rate, was similar between water infusion and standard air insufflation (risk ratio 1.00, 95% confidence interval (CI) 0.97 to 1.03, P = 0.93). Adenoma detection rate, that is number of participants with at least one detected adenoma, was slightly improved with water infusion (risk ratio 1.16, 95% CI 1.04 to 1.30, P = 0.007). Assuming the fraction of patients undergoing screening colonoscopy who had one or more adenomas detected was 20 per 100 with standard colonoscopy, the use of water colonoscopy may increase the fraction to 23 per 100 individuals. From our findings, it is possible that up to 68,000 more of the 1.7 million outpatient screening colonoscopies performed annually in the United States, could detect adenomas if water infusion colonoscopy was used. In addition, with water infusion participants experienced significantly less pain (mean difference in pain score on a 0 to 10 scale: -1.57, 95% CI -2.00 to -1.14, P < 0.00001) and a significantly lower proportion of participants requested on-demand sedation or analgesia, or both (risk ratio 1.20, 95% CI 1.14 to 1.27, P < 0.00001). Qualitative analysis suggests that water infusion colonoscopy was not associated with a markedly increased rate of adverse events compared with the standard procedure. AUTHORS' CONCLUSIONS: Completeness of colonoscopy, that is cecal intubation rate, was not improved by water infusion compared with standard air insufflation colonoscopy. However, adenoma detection, assessed with two different measures (that is adenoma detection rate and number of detected adenomas per procedure), was slightly augmented by the water infusion colonoscopy. Improved adenoma detection might be due to the cleansing effects of water infusions on the mucosa. Detection of premalignant lesions during standard colonoscopy is suboptimal, and so improvements in adenoma detection by water infusion colonoscopy, although small, may help to reduce the risk of interval colorectal carcinoma. The most obvious benefit of water infusion colonoscopy was reduction of procedure-related abdominal pain, which may enhance the acceptance of screening/surveillance colonoscopy.
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Adenoma/diagnóstico , Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Insuflación/métodos , Agua , Dolor Abdominal/etiología , Dolor Abdominal/prevención & control , Colonoscopía/efectos adversos , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Agua/administración & dosificaciónRESUMEN
BACKGROUND AND STUDY AIM: It is commonly assumed that ablation of any remaining Barrett's epithelium after endoscopic resection of early Barrett's neoplasia improves outcome by reducing the rate of metachronous lesions, but this has not yet been evaluated in a randomized trial. The aim of this study was to compare argon plasma coagulation (APC) with surveillance only for the management of residual Barrett's epithelium following endoscopic resection. PATIENTS AND METHODS: Patients in whom focal early Barrett's neoplasia (high grade intraepithelial neoplasia [HGIN] or mucosal cancer) had been curatively resected by endoscopy were randomly assigned to undergo ablation of the residual Barrett's segment by APC or surveillance only; pH-metry-adjusted proton pump inhibitor therapy was administered in both groups. The main outcome parameter was recurrence-free survival. Follow-up endoscopies with biopsies in cases of further residual Barrett's epithelium were carried out at 6-monthly intervals in both groups. RESULTS: A total of 63 patients (57 male [90.5%]) were included in the study (ablation group n=33; surveillance group n=30). For complete Barrett's ablation, a mean number of 4±1.6 APC sessions were required (range 2-7). The mean follow-up duration did not differ significantly between ablation (28.2±13.7 months, range 0-44) and surveillance patients (24.7±14.8 months, range 0-45; P=0.159). The number of secondary lesions was 1 in the ablation group (3%), and 11 in the surveillance group (36.7%), leading to significantly higher recurrence-free survival for the patients undergoing ablation (P=0.005). CONCLUSIONS: Thermal ablation of residual Barrett's epithelium leads to a significant reduction in neoplasia recurrence rate compared with a surveillance strategy during a limited follow-up of 2 years. A longer follow-up duration may have led to a relatively higher rate of secondary neoplasia in both groups of patients.
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Esófago de Barrett/cirugía , Carcinoma in Situ/cirugía , Ablación por Catéter , Neoplasias Esofágicas/cirugía , Espera Vigilante , Adulto , Anciano , Esófago de Barrett/tratamiento farmacológico , Carcinoma in Situ/tratamiento farmacológico , Ablación por Catéter/efectos adversos , Supervivencia sin Enfermedad , Neoplasias Esofágicas/tratamiento farmacológico , Esofagoscopía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasia Residual , Vigilancia de la Población , Inhibidores de la Bomba de Protones/uso terapéuticoRESUMEN
BACKGROUND: Three different classification systems for the evaluation of Barrett's esophagus (BE) using magnification endoscopy (ME) and narrow-band imaging (NBI) have been proposed. Until now, no comparative and external evaluation of these systems in a clinical-like situation has been performed. OBJECTIVE: To compare and validate these 3 classification systems. DESIGN: Prospective validation study. SETTING: Tertiary-care referral center. Nine endoscopists with different levels of expertise from Europe and Japan participated as assessors. PATIENTS: Thirty-two patients with long-segment BE. INTERVENTIONS: From a group of 209 standardized prospective recordings collected on BE by using ME combined with NBI, 84 high-quality videos were randomly selected for evaluation. Histologically, 28 were classified as gastric type mucosa, 29 as specialized intestinal metaplasia (SIM), and 27 as SIM with dysplasia/cancer. Assessors were blinded to underlying histology and scored each video according to the respective classification system. Before evaluation, an educational set concerning each classification system was carefully studied. At each assessment, the same 84 videos were displayed, but in different and random order. MAIN OUTCOME MEASUREMENTS: Accuracy for detection of nondysplastic and dysplastic SIM. Interobserver agreement related to each classification. RESULTS: The median time for video evaluation was 25 seconds (interquartile range 20-39 seconds) and was longer with the Amsterdam classification (P < .001). In 65% to 69% of the videos, assessors described certainty about the histology prediction. The global accuracy was 46% and 47% using the Nottingham and Kansas classifications, respectively, and 51% with the Amsterdam classification. The accuracy for nondysplastic SIM identification ranged between 57% (Kansas and Nottingham) and 63% (Amsterdam). Accuracy for dysplastic tissue was 75%, irrespective of the classification system and assessor expertise level. Interobserver agreement ranged from fair (Nottingham, κ = 0.34) to moderate (Amsterdam and Kansas, κ = 0.47 and 0.44, respectively). LIMITATION: No per-patient analysis. CONCLUSIONS: All of the available classification systems could be used in a clinical-like environment, but with inadequate interobserver agreement. All classification systems based on combined ME and NBI, revealed substantial limitations in predicting nondysplastic and dysplastic BE when assessed externally. This technique cannot, as yet, replace random biopsies for histopathological analysis.
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Esófago de Barrett/clasificación , Esófago de Barrett/patología , Lesiones Precancerosas/clasificación , Lesiones Precancerosas/patología , Anciano , Esofagoscopía/métodos , Femenino , Humanos , Aumento de la Imagen/métodos , Masculino , Persona de Mediana Edad , Membrana Mucosa/patología , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
BACKGROUND & AIMS: The aim of this study was to compare magnified still images obtained with high-resolution white light endoscopy, indigo carmine chromoendoscopy, acetic acid chromoendoscopy, and narrow-band imaging to determine the best technique for use in Barrett's esophagus. METHODS: We obtained magnified images from 22 areas with the 4 aforementioned techniques. Seven endoscopists with no specific expertise in Barrett's esophagus or advanced imaging techniques and 5 international experts in this field evaluated these 22 areas for overall image quality, mucosal image quality, and vascular image quality. In addition, the regularity of mucosal and vascular patterns and the presence of abnormal blood vessels were evaluated, and this was correlated with histology. RESULTS: The interobserver agreement for the 3 features of mucosal morphology with white light images ranged from kappa = 0.51 (95% confidence interval [CI]: 0.46-0.55) to kappa = 0.53 (95% CI: 0.50-0.57) for all observers, from kappa = 0.43 (95% CI: 0.33-0.54) to kappa = 0.53 (95% CI: 0.41-0.64) for experts, and from kappa = 0.51 (95% CI: 0.15-0.33) to kappa = 0.64 (95% CI: 0.58-0.70) for nonexperts. The interobserver agreement in these groups did not improve by adding one of the enhancement techniques. The yield for identifying early neoplasia with white light images was 86% for all observers, 90% for experts, and 84% for nonexperts. The addition of enhancement techniques did not improve the yield neoplasia. CONCLUSIONS: The addition of indigo carmine chromoendoscopy, acetic acid chromoendoscopy, or narrow-band imaging to white light images did not improve interobserver agreement or yield identifying early neoplasia in Barrett's esophagus.
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Ácido Acético , Esófago de Barrett/patología , Colorantes , Neoplasias Esofágicas/patología , Esofagoscopía/métodos , Esófago/patología , Aumento de la Imagen , Carmin de Índigo , Lesiones Precancerosas/patología , Anciano , Anciano de 80 o más Años , Esófago/irrigación sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Membrana Mucosa/patología , Variaciones Dependientes del Observador , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVES: In the West, neither acute nor long-term results of endoscopic resection (ER) for early gastric cancer (EGC) have been reported in large studies. The aim of this study was to prospectively evaluate the efficacy and safety of ER in patients with EGC in a long-term follow-up (FU). METHODS: From May 1995 to October 2004, 179 patients were referred to our department for endoscopic therapy (ET) of gastric cancer (GC). Of these, 43 patients had intramucosal GC with a diameter of up to 30 mm and underwent ER with curative intent. All patients underwent a strict FU protocol at regular intervals. RESULTS: Of the 43 patients, 42 fulfilled our low-risk criteria for ET of EGC: gross tumor type I/II, intramucosal GC, diameter up to 30 mm, tumor differentiation G1/G2, and no infiltration into lymph vessels/veins. Two patients were not available for FU (remission status not evaluated). In another patient, gastric mucosa-associated lymphoid tissue lymphoma was detected simultaneously, and he was referred for surgery. 38 (97%) of the remaining 39 patients who underwent definitive ET (23 males (59%); mean age 69+/-10 years) achieved complete remission (CR) after a mean of 1.3+/-0.6 ER sessions. Minor complications (not Hb-relevant bleeding) occurred in 7 of the 39 patients (18%) and major complications (5 Hb-relevant bleeds, 1 covered perforation; all managed conservatively) in 6 patients (15%). During FUs (mean 57 months; range 5-137), recurrent or metachronous lesions were observed in 11 patients (29%). All lesions were successfully treated by repeated ET. No tumor-related deaths occurred during FU. CONCLUSIONS: Although ER for EGC in Western countries is effective, it is associated with a relevant risk of complications. In view of the possibility of recurrent or metachronous neoplasia, a strict FU protocol is mandatory.
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Endoscopía Gastrointestinal , Neoplasias Gástricas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Endoscopía Gastrointestinal/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Gástricas/patologíaRESUMEN
BACKGROUND & AIMS: Confocal laser endomicroscopy has been shown to allow direct histologic imaging of gastrointestinal tumors in vivo. This study was designed to assess the potential of endomicroscopy for predicting histology in vivo during routine endoscopy in patients with early squamous cell cancer. METHODS: Twenty-one consecutive patients with suspected early squamous cell cancer who had been referred for endoscopic therapy to a tertiary-care academic medical center were included in this prospective study. After staining with 0.5% Lugol's solution and injection of 500 mg fluorescein sodium, unstained mucosal areas were examined using confocal imaging. Images of each scanned lesion were acquired and stored digitally, and in vivo diagnosis was performed during ongoing endoscopy. Biopsy specimens were taken from every lesion. The confocal images were reviewed by 2 endoscopists, who were blinded to the histology and endoscopic appearance. RESULTS: Confocal images were acquired from 43 lesions in 21 patients. Twenty-seven of the 43 lesions (63%) were proven to be squamous cell cancer on histology. All squamous cell cancers were diagnosed correctly by endomicroscopy and 2 lesions were falsely diagnosed as neoplastic. The overall accuracy was 95%, and the sensitivity and specificity were 100% and 87%, respectively. Intraobserver agreement was almost perfect (kappa = 0.95) and interobserver agreement was substantial (kappa = 0.79). CONCLUSIONS: Confocal laser endomicroscopy is able to provide virtual histology of early squamous cell cancers with a high degree of accuracy and can facilitate rapid diagnosis during routine endoscopy.
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Carcinoma de Células Escamosas/diagnóstico , Diagnóstico Precoz , Neoplasias Esofágicas/diagnóstico , Esofagoscopía , Microscopía Confocal/métodos , Esófago/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Endoscopic therapy (ET) has become a less risky alternative to open surgery in mucosal Barrett's cancer (BC) because of the very low risk of lymph node (LN) metastasis. Recently published surgical series demonstrated that even in case of minimal submucosal invasion of BC, the risk for LN metastasis is very low. In consequence, also these patients might be eligible for curative ET. The aim of this study was to prospectively evaluate the efficacy and safety of endoscopic resection (ER) in these patients. METHODS: From September 1996 to September 2003, the suspicion or definite diagnosis of submucosal BC was made in 80 patients referred to our department. Of those, 21 patients (20 male [95.2%], mean age 62 +/- 9 yr, range 47-78) fulfilled the definition of "low-risk" submucosal cancer: invasion of the upper submucosal third (sm1), absence of infiltration into lymph vessels/veins, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with or without an additive ablation of non-neoplastic remnants of Barrett's esophagus. RESULTS: One of the 21 patients was referred to surgery directly after the detection of sm1 invasion at the beginning of the study. One patient died (not tumor-related) before completion of ET. Using definitive ET, complete remission (CR) was achieved in 18 of 19 patients (95%) after a mean of 5.3 months (range 1-18) and a mean of 2.9 resections (range 1-9). Only one minor complication (bleeding without drop in hemoglobin level >2 g/dL) occurred (5% of patients). During a mean follow-up (FU) of 62 months (range 45-89), recurrent or metachronous carcinomas were found in 5 patients (28%). Repeat ET was carried out successfully using ER (4 patients) and argon plasma coagulation (1 patient). In one of the 19 patients (5%), tumor freedom had not been achieved after a total of 2 ER. This patient died of a heart attack before surgery could be performed. The calculated 5-yr survival rate of all 21 patients was 66%. No tumor-related death occurred. CONCLUSIONS: As in mucosal BC, ER is associated with favorable outcomes even in case of "low-risk" submucosal BC. Further and larger clinical trials are required before a general recommendation for ER as the treatment of choice in "low-risk" submucosal BC can be given.
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Esófago de Barrett/patología , Carcinoma/patología , Endoscopía Gastrointestinal/métodos , Neoplasias Esofágicas/patología , Mucosa Intestinal/patología , Invasividad Neoplásica , Anciano , Esófago de Barrett/diagnóstico por imagen , Esófago de Barrett/cirugía , Carcinoma/cirugía , Diagnóstico Diferencial , Endosonografía , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/cirugía , Femenino , Estudios de Seguimiento , Humanos , Mucosa Intestinal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
A 70-year-old woman presented with a persistent, nonmalignant esophagorespiratory fistula. Since other treatment options failed or were denied, an experimental nonsurgical therapy was performed. A self-expanding ventricular septal defect (VSD) occlusion device (Amplatzer; AGA Medical Corporation; Golden Valley, MN) was bronchoscopically introduced to close the fistula. The double umbrella-like occlusion device is made from nitinol mesh and closes luminal contact between the esophageal and bronchial walls, with its waist filling out the fistula itself. The geometry of the occluder system can in theory be designed according to individual purposes and needs. The performed treatment was safe and successful, and the patient remained asymptomatic for 1 year after the first presentation. The treatment of chronic nonmalignant esophagorespiratory fistulas can be difficult. The self-expanding VSD occluder system described in this case might be useful in patients who are not surgical candidates.
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Broncoscopía/métodos , Endoscopía/métodos , Equipos y Suministros , Fístula Esofágica/cirugía , Esofagoscopía/métodos , Fístula del Sistema Respiratorio/cirugía , Anciano , Femenino , Defectos del Tabique Interventricular/cirugía , Humanos , Prótesis e ImplantesRESUMEN
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BACKGROUND: A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients. METHODS: Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL. RESULTS: Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9-3.5)), (2) size of stones >17 mm (1.7 (1.4-2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1-1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75-91%) for solitary stones <16 mm, 79% (70-86%) for solitary stones > or =16 mm with a CT density <84 H, 45% (32-55%) for solitary stones > or =16 mm with a CT density > or =84 H, and 42% (30-51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39-47%). CONCLUSIONS: ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.
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Cálculos Biliares/terapia , Litotricia/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Métodos Epidemiológicos , Femenino , Cálculos Biliares/diagnóstico por imagen , Cálculos Biliares/patología , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Pronóstico , Recurrencia , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: This is a review of endoscopic therapy in the setting of palliative management of patients suffering from esophageal cancer (EC). Unfortunately, many cases of EC present in a stage of disease in which curative therapy is not possible. The maintenance of quality of life includes the ability to swallow and of oral feeding, pain control, and the prevention of bleeding. METHODS: A review of the current literature was performed. RESULTS: Many endoscopic methods are available for the management of dysphagia, of which dilation, endoluminal tumor destruction, stenting, and brachytherapy are the most common. CONCLUSION: Surgical palliation should be avoided as much as possible since the alternatives show at least the same efficacy and have fewer complications.
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Endoscopic resection (ER) has gained more and more importance in the treatment of early gastrointestinal neoplasia over the last few years. The choice of the different available techniques depends on the site, the macroscopic type of the tumour and the personal experience of the endoscopist. The 'suck-and-cut' technique with ligation device or cap should be favoured to normal strip biopsy in the oesophagus because of the size of the resected specimen and its technical feasibility. A recently described method of ER in the stomach is the circumferential mucosal incision with a type of needle-knife and subsequent en-bloc resection following prior injection under the lesions. ER of high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus should be considered as the treatment of choice. First mid-term results of endoscopic therapy of early squamous-cell neoplasia in the oesophagus show promising results; however, long-term results are awaited. Studies with large numbers of patients in Japan proved the efficiency and safety of ER in low-risk early gastric carcinoma. Duodenal lesions and adenomas of the major duodenal papilla were also proved to be treated successfully by ER. In the colon, ER is used successfully for resection of adenomas and small well-differentiated or moderately differentiated carcinomas that are restricted to the mucosa. ER of gastrointestinal lesions is a safe and effective method but should be performed only by experienced endoscopists.
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Endoscopía/métodos , Neoplasias Gastrointestinales/patología , Neoplasias Gastrointestinales/cirugía , Lesiones Precancerosas/patología , Lesiones Precancerosas/cirugía , Esófago de Barrett/patología , Esófago de Barrett/cirugía , Biopsia con Aguja , Ensayos Clínicos como Asunto , Endoscopía/efectos adversos , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Femenino , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Estadificación de Neoplasias , Medición de Riesgo , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugía , Resultado del TratamientoRESUMEN
The assumption that the endoscopist is an important factor in outcome of ERCP is not easy to document. There are plenty of reasons for the difficulties in defining experience and skill of an endoscopist, and establishing suitable endpoints for their measurement. Suitable proxy variables are ERCP-frequency (ongoing volumes) and ERCP-experience (life-time volumes) of the endoscopist, as well as individual and institutional conditions. Important confounders are difficulty of ERCP, patient-related and procedure-related risk factors and risk-reducing factors. Endpoints should include success and (specific) complications of ERCP. Only few studies are available that analyse the influence of the endoscopist's skills on post-ERCP pancreatitis. Studies with a high preponderance of dominating patient-related risk factors for post-ERCP pancreatitis, e.g. suspect of SOD and unexplained abdominal pain, failed to prove such a dependence. On the other hand, evidence increases from studies with patient populations of more traditional indications for ERCP that suggests the existence of an association between ERCP-frequency of the endoscopist or ERCP-frequency of the environment and the incidence of post-ERCP pancreatitis and other complications. ERCP-experience measured in overall live-time volumes, however, does not seem to influence the risk of pancreatitis due to ERCP, although the data are very limited. During the ERCP-training of young endoscopists an impaired success rate appears more important than an increased complication rate. Nevertheless, all undesired outcomes of ERCP should be applied to the endpoints of quality assessment in ERCP-training. Further studies on this topic are needed. Since many variables significantly interact with the endpoints post-ERCP pancreatitis and complications of ERCP, a special study design appears indispensable to conclusively prove a relationship between an endoscopist's expertise and specific complications of ERCP.
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Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Competencia Clínica , Pancreatitis/etiología , Endoscopía/educación , Humanos , Factores de Riesgo , Resultado del TratamientoAsunto(s)
Carcinoma de Células Escamosas/cirugía , Endoscopía/métodos , Neoplasias Esofágicas/cirugía , Esófago de Barrett/patología , Esófago de Barrett/cirugía , Carcinoma de Células Escamosas/patología , Diagnóstico Precoz , Neoplasias Esofágicas/patología , Femenino , Humanos , Masculino , Resultado del TratamientoRESUMEN
OBJECTIVES: Standard colonoscopy offers no reliable discrimination between neoplastic and nonneoplastic colorectal lesions. Computed virtual chromoendoscopy with the Fujinon intelligent color enhancement (FICE) system is a new dyeless imaging technique that enhances mucosal and vascular patterns. This prospective trial compared the feasibility of FICE, standard colonoscopy, and conventional chromoendoscopy with indigo carmine in low- and high-magnification modes for determination of colonic lesion histology. METHODS: Sixty-three patients with 150 flat or sessile lesions less than 20 mm in diameter were enrolled. At colonoscopy, each lesion was observed with six different endoscopic modalities: standard colonoscopy, FICE, and conventional chromoendoscopy with indigo carmine (0.2%) dye spraying in both low- and high-magnification modes. Histopathology of all lesions was confirmed by evaluation of endoscopic resection or biopsy specimens. Endoscopic images were stored electronically and randomly allocated to a blinded reader. RESULTS: Of the 150 polyps, 89 were adenomas and 61 were hyperplastic polyps with an average size of 7 mm. For identifying adenomas, the FICE system with low and high magnifications revealed a sensitivity of 89.9% and 96.6%, specificity of 73.8% and 80.3%, and diagnostic accuracy of 83% and 90%, respectively. Compared with standard colonoscopy, the sensitivity and diagnostic accuracy achieved by FICE were significantly better under both low (P < 0.02) and high (P < 0.03) magnification and were comparable to that of conventional chromoendoscopy. CONCLUSIONS: The FICE system identified morphological details that efficiently predict adenomatous histology. For distinguishing neoplastic from nonneoplastic lesions, FICE was superior to standard colonoscopy and equivalent to conventional chromoendoscopy.
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Colonografía Tomográfica Computarizada , Neoplasias Colorrectales/diagnóstico , Procesamiento de Imagen Asistido por Computador , Adulto , Anciano , Anciano de 80 o más Años , Pólipos del Colon/diagnóstico , Colonoscopía , Colorantes , Femenino , Humanos , Aumento de la Imagen , Carmin de Índigo , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Sensibilidad y EspecificidadRESUMEN
BACKGROUND AND STUDY AIMS: Screening for specialized columnar epithelium (SCE) within columnar lined esophagus (CLE) with standard video endoscopes is not reliable enough. Several methods to improve accuracy of predicting presence of SCE like chromoendoscopy with vital stains or structure enhancement with acetic acid have been introduced but data up to now remains controversial. The present prospective study was conducted to evaluate a combination of chromoendoscopy and acetic acid structure enhancement using the naturally brownish coloured balsamic vinegar during routine upper endoscopy. PATIENTS AND METHODS: Between March and July 2006 20 patients with macroscopic suspicion for SCE during routine endoscopy were included prospectively. Saline diluted balsamic vinegar (3%) was administered with a spraying catheter at the distal esophagus. After 1 minute the distal esophagus was evaluated for the presence of SCE according to the mucosal surface pattern (pattern I-II: round pits/circular pattern predicting gastric epithelium; pattern III-IV: ridged/villous pattern predicting Barrett's epithelium). Only HR-videoendoscopes without magnification were used. After presence or absence of SCE was defined by the endoscopist targeted biopsies of the CLE were performed. Histological results were compared with endoscopic findings. RESULTS: In 9 of 20 patients (13 male, 7 female; mean age 60.0 +/- 12.8 years) biopsy specimen revealed SCE within CLE on histology. Prediction of BM after balsamic vinegar staining was possible in all cases. Surface pattern I-II was found in 9 patients and pattern III-IV in 11 patients. Accuracy, sensitivity and specificity for BV staining predicting SCE were 90%, 100% and 82%, respectively. CONCLUSION: Chromoendoscopy with balsamic vinegar combines the advantages of chromoendoscopy and structure enhancement by acetic acid for detection of SCE. The reliability in predicting the presence of SCE was high in this prospective feasibility study.