Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett's Esophagus: World Endoscopy Organization Delphi Study.

BACKGROUND & AIMS: Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. METHODS: The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. RESULTS: After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. CONCLUSIONS: We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.

Principles and practice to facilitate complete photodocumentation of the upper gastrointestinal tract: World Endoscopy Organization position statement.

Although esophagogastroduodenoscopy (EGD) is the most commonly used procedure in the gastrointestinal (GI) tract, the method of esophageal, gastric and duodenal mucosa photodocumentation varies considerably worldwide. One probable explanation is that for generations, EGD has primarily been taught by GI faculty and instructors based on their perceptions and experience, which has resulted in EGD being a non-standardized procedure. Currently, the procedure is facing a challenging scenario as endoscopy societies are implementing procedure-associated quality indicators aiming for best practice among practitioners and evidence-based care for patients. Contrary to colonoscopy where cecum landmarks photodocumentation is considered proof of completeness, there are currently no reliable performance measures to gauge the completeness of an upper endoscopy nor guidance for complete photodocumentation. This World Endoscopy Organization (WEO) position statement aims to provide practical guidance to practitioners to carry out complete EGD photodocumentation. Hence, an international group of experts from the WEO Upper GI Cancer Committee formulated the following document using the body of evidence established through literature reviews, expert opinions, and other scientific sources. The group acknowledged that although the procedure should be feasible in any facility, what is needed to achieve a global shift on the concept of completeness is a common written statement of agreement on its potential impact and added value. This best practice statement offers endoscopists principles and practical guidance in order to carry out complete photodocumentation from the hypopharynx to the second duodenal portion.

[Detection of polyps, adenomas, advanced adenomas and adenocarcinomas in patients between 45 and 49 years]. / Detección de pólipos, adenomas, adenomas avanzados y adenocarcinomas de colon en pacientes entre 45 y 49 años.

UNLABELLED: BACKGROUND. Colorectal cancer (CRC) can be prevented. Colonoscopy is the first-line procedure for screening in average risk population. In 2002, Imperiale evaluated people between 40 to 49 years and reported that adenomas and advanced adenomas presented in 8.5% and 3.5% of cases, respectively. Currently, no recommendations for CRC screening in this population have been made. OBJECTIVE: To estimate the prevalence ofpolyps, adenomas, advanced lesions and adenocarcinomas in the 45- to 49-year-old population. METHODS: We included consecutive adults between 45 and 49 years old who performed colonoscopy because of gastrointestinal signs or symptoms. Exclusion criteria were high risk for CRC, incomplete VCC and/or previous evidence of colonic lesions. The study was conducted in a gastroenterology center from Buenos Aires, between September 2010 and October 2011. The design was prospective and cross-sectional. Polyethylene glycol (PEG) lavage solution or phosphates were usedfor cleansing. Colonoscopies were performed under sedation with Olympus equipment. The protocol was approved by the local IRB. 95% confidence intervals (95% CI) were estimated. RESULTS: 814 patients were evaluated and 764 were included, 440 (57%) were women and the average age was 47 years. The global prevalence of polyps was 20% (160 cases, 95% CI 18%-24%). The global prevalence of adenomas was 14% (107 cases, 95% CI 11%-16%). The prevalence of advanced adenomas was 5% (39 cases, 95% CI 4%-7%) and the prevalence of adenocarcinoma was 0.1% (1 case, 95% CI 0%-0.7%). CONCLUSIONS: The prevalence of lesions in this population is lower than that in the average risk population. At the moment we do understand that there is no evidence to recommend CRC screening in 45- to 49-year-old individuals.

Management of early-stage esophageal neoplasia (MESEN) consensus.

BACKGROUND: Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario. METHODS: Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article. RESULTS: There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates. CONCLUSION: Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.

[Prevalence of rectosigmoid adenomas and adenocarcinomas in patients younger than 50 years old referred for proctorrhagia]. / Prevalencia de adenomas y adenocarcinomas de recto-sigma en pacientes menores de 50 años que consultan por proctorragia.

BACKGROUND: Rectal bleeding is a sign of colorectal cancer (CRC). Its early diagnosis decreases mortality and improves survival. In young population with no risk factors for the disease, CRC is infrequent. Moreover, benign anorectal disorders are most frequent causes of bleeding and generally, when anal pathology is identified, it is assumed as the origin of the sign. For all these reasons, rectal bleeding sometimes is sub-assessed in young patients. OBJECTIVE: Estimate the prevalence of adenomas and adenocarcinomas in sigmoid and rectum in patients younger than 50 years old referred for proctorrhagia. METHODS: The study design was descriptive, retrospective and cross-sectional. Procedures were performed under sedation and Olympus CF 160 y CF 180 scopes were used. Proctorrhagia was considered as rectal bleeding registered as indication of the procedure. Histology was established according to Vienna classification. Informed consent was signed before the procedures. Colonoscopy reports were reviewed. The study took place in an outpatient clinic in Buenos Aires city, between October 2010 and October 2011. High risk patients for CRC were excluded RESULTS: We included 1,203 from 1,257 reviewed VCC, 49% were female and the median age was 38 years old (range: 18-49 years old). The prevalence of adenomas and adenocarcinomas in sigmoid and rectum was 67% [95% confidence interval (95% CI): 5.4-8.3] and 1.6% (95% CI 1-2.5), respectively. CONCLUSIONS: Adenocarcinomas and adenomas are infrequent in a young population without risk factors for CRC. However, even when benign anal disorders are the most frequent cause for rectal bleeding, miss evaluation of this sign could have a serious impact in almost 10 of 100 individuals.

Prevalencia de adenomas y adenocarcinomas de recto-sigma en pacientes menores de 50 años que consultan por proctorragia / [Prevalence of rectosigmoid adenomas and adenocarcinomas in patients younger than 50 years old referred for proctorrhagia].

BACKGROUND: Rectal bleeding is a sign of colorectal cancer (CRC). Its early diagnosis decreases mortality and improves survival. In young population with no risk factors for the disease, CRC is infrequent. Moreover, benign anorectal disorders are most frequent causes of bleeding and generally, when anal pathology is identified, it is assumed as the origin of the sign. For all these reasons, rectal bleeding sometimes is sub-assessed in young patients. OBJECTIVE: Estimate the prevalence of adenomas and adenocarcinomas in sigmoid and rectum in patients younger than 50 years old referred for proctorrhagia. METHODS: The study design was descriptive, retrospective and cross-sectional. Procedures were performed under sedation and Olympus CF 160 y CF 180 scopes were used. Proctorrhagia was considered as rectal bleeding registered as indication of the procedure. Histology was established according to Vienna classification. Informed consent was signed before the procedures. Colonoscopy reports were reviewed. The study took place in an outpatient clinic in Buenos Aires city, between October 2010 and October 2011. High risk patients for CRC were excluded RESULTS: We included 1,203 from 1,257 reviewed VCC, 49

were female and the median age was 38 years old (range: 18-49 years old). The prevalence of adenomas and adenocarcinomas in sigmoid and rectum was 67

CI): 5.4-8.3] and 1.6

CI 1-2.5), respectively. CONCLUSIONS: Adenocarcinomas and adenomas are infrequent in a young population without risk factors for CRC. However, even when benign anal disorders are the most frequent cause for rectal bleeding, miss evaluation of this sign could have a serious impact in almost 10 of 100 individuals.

Prevalencia de adenomas y adenocarcinomas de recto-sigma en pacientes menores de 50 años que consultan por proctorragia. / [Prevalence of rectosigmoid adenomas and adenocarcinomas in patients younger than 50 years old referred for proctorrhagia].

BACKGROUND: Rectal bleeding is a sign of colorectal cancer (CRC). Its early diagnosis decreases mortality and improves survival. In young population with no risk factors for the disease, CRC is infrequent. Moreover, benign anorectal disorders are most frequent causes of bleeding and generally, when anal pathology is identified, it is assumed as the origin of the sign. For all these reasons, rectal bleeding sometimes is sub-assessed in young patients. OBJECTIVE: Estimate the prevalence of adenomas and adenocarcinomas in sigmoid and rectum in patients younger than 50 years old referred for proctorrhagia. METHODS: The study design was descriptive, retrospective and cross-sectional. Procedures were performed under sedation and Olympus CF 160 y CF 180 scopes were used. Proctorrhagia was considered as rectal bleeding registered as indication of the procedure. Histology was established according to Vienna classification. Informed consent was signed before the procedures. Colonoscopy reports were reviewed. The study took place in an outpatient clinic in Buenos Aires city, between October 2010 and October 2011. High risk patients for CRC were excluded RESULTS: We included 1,203 from 1,257 reviewed VCC, 49

were female and the median age was 38 years old (range: 18-49 years old). The prevalence of adenomas and adenocarcinomas in sigmoid and rectum was 67

[95

confidence interval (95

CI): 5.4-8.3] and 1.6

(95

CI 1-2.5), respectively. CONCLUSIONS: Adenocarcinomas and adenomas are infrequent in a young population without risk factors for CRC. However, even when benign anal disorders are the most frequent cause for rectal bleeding, miss evaluation of this sign could have a serious impact in almost 10 of 100 individuals.

[Adherence of physicians to colorectal cancer screening: which is their compliance to this strategy?]. / Adherencia de la población médica a los programas de rastreo de cáncer colorrectal: ¿Cuál es el cumplimiento de esta medida preventiva entre los profesionales?

BACKGROUND: Colorectal cancer (CRC) screening is strongly recommended as early diagnosis improves survival and reduces mortality. However, the adherence in general population is about 50% and even lower among physicians. OBJECTIVE: 1) To estimate the percentage of physicians that had done a screening test. 2) To estimate the frequency of tests used by these professionals. METHODS: We conducted an anonymous survey among 269 physicians, 50-year-old or more, from four hospitals and four scientific conventions in 2008. This validated survey included specialty, family history, compliance to screening, clinical features at screening, age, tests used reasons for having or not done the tests and results. RESULTS: Twenty-four hundred and two data surveys were included (response rate 90%). Average age was 58+6 years. Specialties were Internal Medicine (72%), Surgery (18%) and others (9%). One hundred physicians had a test done [41% (IC95% 35-47)]. The most used test was colonoscopy [70% (IC 95% 60-78)], followed by barium enema [10% (IC 95% 5-18)]. From screened physicians, 36% had family history of CRC, 63% did not and 1% was unaware of this antecedent. Physicians referred the following reasons for not being compliant: personal decision, fear of the procedure, insufficient knowledge of guidelines and lack of time. CONCLUSIONS: The compliance of physicians to CRC screening is suboptimal. New strategies should be implemented to achieve changes in health habits of physicians and compliance to preventive strategies.

Gastrostomía percutánea: variantes técnicas / Percutaneous gastrostomy: different techniques

Antecedentes: Los pacientes que no pueden ingerir alimentos por boca durante un prolongado período de tiempo requieren un soporte nutricional enteral o parenteral. Desde 1980 se realizan para este propósito las gastrostomías percutáneas. Objetivo: Comentar la experiencia con la técnica percutánea y su modificación mediante la visualización endoscópica. Lugar de aplicación: Sección Cirugía Percutánea, División Cirugía Gastroenterológica, Hospital Universitario. Diseño: Retrospectivo. Análisis de casos. Población: Se realizaron 94 gastrostomías percutáneas o gastroyeyunostomías percutáneas. Cincuenta y un pacientes pertenecían al sexo masculino y la edad promedio fue de 61 años. En 39 oportunidades se utilizó la técnica endoscópica, en 32 la radiológica y en 23 una técnica combinada. Método: Se analizaron indicaciones, técnicas y complicaciones. Resultados: No se observaron complicaciones durante el procedimiento ni mortalidad referida al método. La mortalidad dentro de los 30 días en 70 pacientes seguidos fue del 5,7 por ciento. Catorce pacientes (14,9 por ciento) presentaron complicaciones luego del procedimiento. Conclusiones: Las diferentes técnicas percutáneas son seguras y efectivas; los puntos percutáneos (gastropexia) no implican morbilidad o tiempo adicional y disminuirían la posibilidad de filtración en las primeras semanas y por último, la técnica combinada es sencilla y de fácil aprendizaje

Gastrostomía percutánea: variantes técnicas / Percutaneous gastrostomy: different techniques

Antecedentes: Los pacientes que no pueden ingerir alimentos por boca durante un prolongado período de tiempo requieren un soporte nutricional enteral o parenteral. Desde 1980 se realizan para este propósito las gastrostomías percutáneas. Objetivo: Comentar la experiencia con la técnica percutánea y su modificación mediante la visualización endoscópica. Lugar de aplicación: Sección Cirugía Percutánea, División Cirugía Gastroenterológica, Hospital Universitario. Diseño: Retrospectivo. Análisis de casos. Población: Se realizaron 94 gastrostomías percutáneas o gastroyeyunostomías percutáneas. Cincuenta y un pacientes pertenecían al sexo masculino y la edad promedio fue de 61 años. En 39 oportunidades se utilizó la técnica endoscópica, en 32 la radiológica y en 23 una técnica combinada. Método: Se analizaron indicaciones, técnicas y complicaciones. Resultados: No se observaron complicaciones durante el procedimiento ni mortalidad referida al método. La mortalidad dentro de los 30 días en 70 pacientes seguidos fue del 5,7 por ciento. Catorce pacientes (14,9 por ciento) presentaron complicaciones luego del procedimiento. Conclusiones: Las diferentes técnicas percutáneas son seguras y efectivas; los puntos percutáneos (gastropexia) no implican morbilidad o tiempo adicional y disminuirían la posibilidad de filtración en las primeras semanas y por último, la técnica combinada es sencilla y de fácil aprendizaje (AU)

Empleo de prótesis expandibles metálicas en el tubo digestivo / Use of metalic expandible prothesis in digestive tract

Se presenta la experiencia en el empleo de prótesis expandibles metálicas en patología neoplásica del tubo digestivo. Entre enero de 1993 y agosto de 1996 colocamos 35 prótesis expandibles metálicas en 33 pacientes, la edad promedio fue de 76 años (50-94). Veintiseis pacientes se presentaron con disfagia, uno con fístula traqueoesofágica con neumopatía y seis con obstrucción intestinal por estenosis colorrectal. Observamos 33 por ciento de complicaciones mayores; hemorragia, migración de la prótesis y oclusión.La mortalidad dentro de los 30 días fue del 7,4 por ciento. En las estenosis altas se obtuvo una adecuada paliación de la disfagia y en las estenosis colorrectales permitió resolver la oclusión intestinal como tratamiento definitivo o prequirúrgico, evitando las intervenciones complejas de urgencia y favoreciendo operaciones en un tiempo. Futuros estudios prospectivos deberán evaluar el costo beneficio de estos nuevos procedimientos

Empleo de prótesis expandibles metálicas en el tubo digestivo / Use of metalic expandible prothesis in digestive tract

Se presenta la experiencia en el empleo de prótesis expandibles metálicas en patología neoplásica del tubo digestivo. Entre enero de 1993 y agosto de 1996 colocamos 35 prótesis expandibles metálicas en 33 pacientes, la edad promedio fue de 76 años (50-94). Veintiseis pacientes se presentaron con disfagia, uno con fístula traqueoesofágica con neumopatía y seis con obstrucción intestinal por estenosis colorrectal. Observamos 33 por ciento de complicaciones mayores; hemorragia, migración de la prótesis y oclusión.La mortalidad dentro de los 30 días fue del 7,4 por ciento. En las estenosis altas se obtuvo una adecuada paliación de la disfagia y en las estenosis colorrectales permitió resolver la oclusión intestinal como tratamiento definitivo o prequirúrgico, evitando las intervenciones complejas de urgencia y favoreciendo operaciones en un tiempo. Futuros estudios prospectivos deberán evaluar el costo beneficio de estos nuevos procedimientos (AU)

Progresos en el diagnóstico y tratamiento de las afecciones tumorales biliopancreaticas / Progress in the diagnosis and treatment of the biliopancreatic tumors affections

Se trata de un estudio multidisciplinario en base a experiencia propia. Se ha revisado bibliografía reciente [3 últimos años] citándose trabajos anteriores sólo cuando tiene interés histórico o tiene relevancia. La Clínica adolece de falta de diagnóstico precoz y ausencia de signos y síntomas específicos. Se destacan la pérdida de peso, ictericia, prurito y dolor. Puede existir colangitis y se halla una masa abdominal palpable entre el 23 y 30 p.cto. de los casos. El laboratorio no es específico salvo en el caso de páncreas con los antígenos tipo CEA CA 19.9 y CA 50 con sensibilidad del 85 al 90 p.cto.. ANATOMIA PATOLOGICA: Se analiza el tipo de carcinoma de vesícula predominantemente adenocarcinomas, considerándose que se originan a través de secuencia de metaplasia intestinal, displasia y carcinoma in situ. El carcinoma de las vías biliares es de tipo adenocarcinoma con gran componente fibroso y es más frecuente en el tercio superior de la misma [50 a 75 p.cto.]. El carcinoma ductal es el más frecuente [85 p.cto.] de los cánceres de páncreas y tiene una incidencia creciente de población. Es común al diagnosticarlo su diseminación al duodeno, retroperitoneo e hígado. Se analizan otros tumores más raros y se insiste en el diagnóstico del insulinoma. Los tumores ampulares tienen implicancia histogénetica pues se desarrollan sobre mucosa de tipo intestinal. EL DIAGNOSTICO POR IMAGENES [ECO y TAC]: Estos métodos muestran la dilatación de la vía biliar, ubican la lesión, cuantifican su tamaño y muestran su invasión y diseminación. La sensibilidad y especificidad de ambos métodos es muy alta. La punción percutánea [PAAF] con ayuda de ECO o TAC demostró ser un método sencillo, rápido y eficaz para diagnosticar los tumores de páncreas. En nuestro grupo tuvo una exactitud del 80 p.cto. y una sensibilidad del 77 p.cto.. La opacificación biliar ya sea por P.T.C. y E.R.C.P. permite con una mínima morbimortalidad, mapear la vía biliar y pancreática. Esto ayuda al cirujano y facilita efectuar biopsias y tratamientos endoscópicos y percutáneos. La laparoscopía puede ser útil para estadificar con histología y para morbilidad estos tumores... (TRUNCADO)(AU)