Interobserver concordance for endoscopic ultrasonography-guided fine-needle aspiration on-site cytopathology.

INTRODUCTION: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an accurate method of diagnosing and staging gastrointestinal and thoracic malignancy. A key issue in maximizing FNA accuracy is to ensure that an adequate specimen is obtained. On-site cytopathology increases the diagnostic yield of EUS-FNA. However, this increases the time and costs. Physicians trained in EUS and in pathology are capable of interpreting cytologic adequacy from EUS-FNA specimens. Furthermore, on-site interpretation by the endoscopist could reduce cost and procedure duration. The learning curve of endossonographers in on-site cytopathology and how they could contribute in EUS-FNA accuracy increase is unknown. OBJECTIVE: To determine the interobserver concordance of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers trained in cytology with a physician cytopathologist. METHODS: A prospective blinded study comparing one endossonographer with one physician cytopathologist. The study was developed in the Santa Casa Medical School, Brazil from February to November 2012. Fifteen different cases of EUS-FNA were analysed, in a total of 50 slides. Each observer described the slides for the adequate or not of tissue sampling, and classified as benign, suspicious, malign or undefined. The analyses were then matched. RESULTS: We analyzed the concordance of 50 slides description made by the endossonographer and physician cytopathologist, according to enough material, cellular group identification and final diagnosis. Kappa (κ) indexes were: Presence of material κ = 0.480 (P < 0.001); presence of malignance κ = 0.808 (P < 0.001); in subepithelial lesions κ = 0.615 (P = 0.06); in pancreatic lesions κ = 0.675 (P < 0.001); in mediastinal lesions κ = 0.243 (P = 0.128). CONCLUSION: Our study showed that endosonographers and cytopathologists had good concordance in EUS-FNA specimens on-site cytopathology interpretation, except in mediastinal/pulmonary cases.

Relevance of endoscopic ultrasound in the management of esophagus cancer therapy.

INTRODUCTION: The objective of this case series study by retrospective analysis was to determine the relevance of endoscopic ultrasound (EUS) in therapeutic decision esophageal cancer. MATERIAL AND METHODS: Using medical records of the Department of Endoscopy of Santa Casa de São Paulo, we have collected data from 16 patients, in 4 years, diagnosed of esophageal cancer, and presented in the form of clinical cases to a specialist surgeon in esophageal cancer and a clinical oncologist, for therapeutic evaluation before and after the outcome of EUS. RESULTS: Both of them choose non-resective and not curative methods (68.8% by surgeon vs. 87.5% oncologist) before EUS. The best treatment by the surgeon was chemotherapy and palliative radiotherapy associated (25%) and palliative endoscopic prostheses (25%), and by the oncologist, neoadjuvant chemotherapy and radiotherapy associated (56.2%). After EUS, the resective surgical treatment was the both choice in only 6.2% of cases, and the rest of 93.8%, non-resective. The surgeon choice was chemotherapy and palliative radiotherapy associated (44%), and oncologist choice was neoadjuvant chemotherapy and radiotherapy associated (44%). Analysis by the Chi-square method, comparing respective versus non-resective treatment, surgeon versus oncologist, with and without the EUS, obtained values of P = 0.39 and P = 0.46, respectively. The comparison between healing and non-healing treatment had the same P value. Regarding the change in behavior (resective vs. non-resective), there was a change of approach by the surgeon in 25% of cases (P = 0.17) and the oncologist moved conduct in 6.25% of cases. Comparing the changing of behavior among experts, the P value was 0.33. Despite evidence of behavior change after the EUS, the statistical point of view, the P value had no significant relevance. The main factor involved is probably due to a reduced number of sample cases. However, this is a pilot study, and is needed other with a larger number of cases. CONCLUSION: The data obtained allow us to conclude that EUS proved to be an important test for the change in staging and therapeutic management of esophageal cancer.

Influence of layer, size and organ of subepithelial lesions of upper gastrointestinal tract in outcomes of endoscopic ultrasound-guided fine-needle aspiration.

INTRODUCTION: The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as a minimally invasive and safe method for material procurement in the differential diagnosis of subepithelial lesions (SEL) of upper gastrointestinal tract (UGT), especially in suspicious lesions of gastrointestinal stromal tumors (GIST). There are few studies discussing the factors that influence the EUS-FNA in the diagnosis of SEL. AIM: To establish possible associations between lesion size, layer and organ of origin with the outcome of EUS-FNA in patients with SELs of UGT. METHODS: A retrospective analysis using data of patients referred to French-Brazilian Center of EUS of endoscopy Department of Santa Casa de São Paulo Hospital, with previous endoscopic diagnosis of SEL, which underwent EUS-FNA from May 2006 to August 2011. RESULTS: A total of 222 patients were submitted to EUS. 15 with extrinsic compressions and 207 with SEL. Of these, 89 underwent to EUS-FNA. Ninety-two SEL were diagnosed on EUS and punctured. The EUS-FNA was positive in 58.7%. In lesions measuring 2-3 cm and >3 cm, the EUS-FNA was positive in 80% and 72%, respectively (P < 0.001). CONCLUSION: The size of SELs was the only variable that influenced the outcome of EUS-FNA. Best results are achieved in lesions larger than 2 cm.

Comparative study of bipolar eletrocoagulation versus argon plasma coagulation for rectal bleeding due to chronic radiation coloproctopathy.

BACKGROUND AND STUDY AIM: Chronic radiation coloproctopathy (CRCP) is a well-recognized complication of radiotherapy, with rectal bleeding the most common presentation. It is frequently refractory to conservative management, but the optimal endoscopic treatment of bleeding secondary to CRCP is still controversial. The efficacy and safety of bipolar eletrocoagulation (BEC) and argon plasma coagulation (APC) in the management of bleeding from CRCP were evaluated and compared. PATIENTS AND METHODS: 30 patients (mean age 67.4 years) with active and chronic bleeding from telangiectasias, were randomly allocated to BEC or APC and stratified by severity of CRCP according to clinical severity and endoscopic findings (Saunders score). Success was defined as eradication of all telangiectasias, and therapeutic failure as need for more than seven sessions or for other treatment. Complications were categorized as minor (e.g. fever, anal or abdominal pain) or major (hemorrhagic). RESULTS: Both treatments were equally effective for the treatment of CRCP rectal bleeding. Only one failure was observed in each group (P = 1.000). There was no significant difference between the two groups regarding number of sessions, minor or major complications, or relapse. However, overall complication rate was significantly higher in the BEC group (P = 0.003). CONCLUSIONS: BEC and APC are both effective for the therapy of bleeding telangiectasias from CRCP. There are probably no major differences between them. Although APC seemed safer than BEC in this investigation, further studies, involving a much larger population, are needed to assess the complication rates and determine the best management option.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis.

AIM: Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC. METHOD: A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection. RESULTS: None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC. CONCLUSION: APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

An evidence-based consensus statement on the role and application of endosonography in clinical practice.

BACKGROUND: Endoscopic ultrasonography (EUS) has evolved over the past 20 years with the emergence of novel diagnostic and therapeutic indications. Our goal was to identify the best evidence supporting the use of EUS. MATERIALS AND METHODS: A six-step approach was employed to develop recommendations using accepted methodology. Twenty-two experienced endosonographers identified topics and reviewed studies using MeSH (medical subject headings) terminology and free text in PubMed. Medline and society abstracts were reviewed if necessary. The quality of evidence, the strength of recommendations, and level of consensus were graded and voted on. RESULTS: Consensus was reached for several clinical scenarios for which the impact of EUS findings was supported by a high level of evidence. These included diagnosis and staging of esophageal cancer, differential diagnosis of subepithelial lesions, thickened gastric folds, assessment of peritoneal involvement in patients with gastric cancer, mucosa-associated lymphoid tissue lymphoma, diagnosis of common bile duct/gallbladder stones, diagnosis of chronic pancreatitis, differential diagnosis of a solid mass in patients with chronic pancreatitis, differential diagnosis of pancreatic cyst, rectal cancer staging, and diagnosis and staging of non-small-cell lung cancer. The recommendations were adopted by the Brazilian Society of Gastrointestinal Endoscopy. Several indications continue to emerge and require additional validation.

[Colonoscopy or sigmoidoscopy: risk of isolated right colon lesions]. / Colonoscopia ou sigmoidoscopia: risco de lesões isoladas no cólon direito.

BACKGROUND: Colorectal cancer is an important cause of death in western countries. Screening methods are based on flexible sigmoidoscopy, a cheap, effective, and less painful procedure, but some important lesions on the right colon can be missed. AIM: Evaluate how many important lesions would be missed if colonoscopy indicated only for patients with distal lesions identified during flexible sigmoidoscopy. MATERIAL AND METHODS: All consecutive colonoscopy performed in the Endoscopy Unit of the Gastroenterology Division of Federal University of São Paulo, SP, Brazil, with polyps and cancer suspicious lesions were reviewed. Patients with a second procedure, inflammatory bowel disease or colonic surgery were excluded. RESULTS: We reviewed 101 patients with 38 possible cancer lesions and 70 polyps. The mean age was 62 years (SD 13.7 years) and 45 were male. Forty five lesions were in the right colon, namely 23 adenomas, 10 adenocarcinomas, 1 lymphoma and 11 benign lesion. Among such lesions, 28 were isolated in the right colon (16 adenomas and 7 adenocarcinomas). CONCLUSION: In our study 23 patients (22.77%) had adenomas or adenocarcinomas isolated in the right colon, that would be missed if flexible sigmoidoscopy was used alone.

Nutritional status improvement in neurologically impaired patients by percutaneous endoscopic gastrostomy feeding.

With increased use of percutaneous endoscopic gastrostomy, it became clear that neurologically impaired patients might benefit from its use. From August 1996 to July 1997, we performed 19 percutaneous endoscopic gastrostomies in patients with neurological sequelae, who were incapable to maintain their nutritional status by oral ingestion or had repeated episodes of aspiration. Sixteen patients were followed prospectively, from 30 days to 11 months (median: 6.4 months). Average weight (38.2 kg to 44.8 kg), BMI (14.8 kg/m2 to 17.8 kg/m2), weight/height ratio (23.5 kg/cm to 28 kg/cm), mid-upper arm circumference (19.4 cm to 21.6 cm) and triceps skinfold thickness (10.3 mm to 12.6 mm) were significantly increased (P < 0.01). Before percutaneous endoscopic gastrostomy, there were 10 (10/16, 62.5%) patients with grade III thinness. In this group, 3/10 patients (30%) showed improvement to grade I (two individuals) and II (one patient). All but five patients (68.75%) were below the fifth percentile of normal distribution for mid-upper arm circumference. One patient (6.2%) showed improvement of her status (between 25th and 50th percentiles). Four patients (25%) started the follow-up below the fifth percentile for normal distribution of triceps skinfold thickness, and showed no improvement. There were no early complications secondary the procedure. Late complications included granulation tissue on ostomy site (18.8%) and ostomy infection (6.2%). Statistical analysis showed significant improvement of anthropometric data. Percutaneous endoscopic gastrostomy is a simple, highly successful and safe procedure, when performed in neurologically impaired patients. It is efficient as a long-term enteral feeding method.

Echoendoscopic evaluation of botulinum toxin intrasphincteric injections in Chagas' disease achalasia.

Botulinum toxin (BT) has recently been indicated as an alternative treatment of idiopathic achalasia with a success rate of 60-70%. One-third of BT-treated cases either fail to respond or fail to sustain the response beyond 6 months. An explanation for BT therapeutic failure would be that the lower esophageal sphincter muscular layer (LES) may be missed as injection is delivered 'blindly'. We aimed to evaluate the percentage of exact endoscopically 'blind' LES punctures using echoendoscopy after the injection of BT for the treatment of Chagas' achalasia (CA). Five patients with CA (mean age 53 years) were randomized to receive 1.2 ml of BT or the same amount of saline injected endoscopically. Echoendoscopy was performed immediately after puncture. Patients were evaluated by the clinical score of dysphagia, radiological examination, upper endoscopy and esophageal manometry and followed up for 6 months. All puncture sites were identified: 17 out of 20 (85%) in the muscle layer and 3 out of 20 (15%) in the submucosa. The three patients in the treatment group showed clinical improvement (average clinical score fell from 14 to 2 after 7 days, and remained at 4 after 6 months of follow-up). The mean pressure of the LES dropped by 29%. Neither patient in the placebo group showed clinical improvement, and the mean pressure of the LES increased by 35%. Endoscopic 'blind' injection of BT into the LES through endoscopy for the management of achalasia is a safe and reproducible technique and has a high percentage of exactness.