AIM:To compare narrow-band imaging(NBI)without image magnification,and chromoendoscopy with Lugol's solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma(SCC)in patients ...AIM:To compare narrow-band imaging(NBI)without image magnification,and chromoendoscopy with Lugol's solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma(SCC)in patients with head and neck cancer.METHODS:This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas,S?o Paulo University Medical School,Brazil,between August 2006 and Feb-ruary 2007.Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed,and the discovered lesions were mapped,recorded and sent for biopsy.The results of the three methods were compared regarding sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood value and negative likelihood value.RESULTS:Of the 129 patients,nine(7%)were diagnosed with SCC,5 of which were in situ and 4 which were intramucosal.All carcinomas were detected through NBI and Lugol chromoendoscopy.Only 4 lesions were diagnosed through conventional examination,all of which were larger than 10 mm.CONCLUSION:NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC,and produces results comparable to those obtained with 2.5%Lugol chromoendoscopy.展开更多
AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS: After obtaining approval of the research ethics committee and informed consent, 20...AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS: After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group).We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the MannWhitney test, χ 2 test, measurement of analysis of variance, and the κ statistic. RESULTS: The times to induction of sedation, recovery, and discharge were shorter in the propofolfentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolamfentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofolfentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION: Deep sedation occurred with propofolfentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.展开更多
AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was...AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.展开更多
The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after st...The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.展开更多
Subepithelial lesions(SELs) in the upper gastrointestinal(GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach ...Subepithelial lesions(SELs) in the upper gastrointestinal(GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound(EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor(GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration(EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions(size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.展开更多
AIM: In order to characterize the qualitative and quantitative microorganisms in different sites of the lower digestive tract (LDT) in healthy volunteers, a specific technique was developed for collecting mucous of th...AIM: In order to characterize the qualitative and quantitative microorganisms in different sites of the lower digestive tract (LDT) in healthy volunteers, a specific technique was developed for collecting mucous of the distal ileum, colon and rectum. METHODS: A polyethylene tube was designed to go through the colonoscope channel with a No. 8 French tube. In order to avoid internal contamination, the distal extremity was protected with a membrane of microfilm after being sterilized in ethilene oxid. To facilitate the aspiration of a precise volume, its interior was coated with silicone. One hundred microlliter (0.1 mL) sample of mucous was collected and transferred into an Eppenddorff tube containing nine hundred microlliter (0.9 mL) of VMGA-3 (viable medium of Goteborg). This procedure was repeated at each site of the LDT with a new sterilized catheter. RESULTS: All sites revealed the "non pathogenic" anaerobic bacteria Veillonella sp (average 105 colony forming units/mL-CFU/mL), allowing to conclude an environment of low oxidation-reduction potential (redox) in the LDT. It was also characterized the presence of Klebisiella sp with significant statistical predominance (SSP) in the ileum. Enterobacter sp was found with SSP in the sigmoid colon, Bacteroides sp non-pigmented (npg) and E.coli with SSP in the sigmoid colon and rectum, Enterococcus sp and Lactobacillus sp with SSP in the rectum, all in a mean concentration of 105 CFU/mL. CONCLUSION: This procedure is feasible and efficient and can point out a similar distribution of the aerobic and anaerobic bacteria with the presence of biological markers of normal microbiota in the LDT.展开更多
BACKGROUND Many studies evaluated magnification endoscopy(ME)to correlate changes on the gastric mucosal surface with Helicobacter pylori(H.pylori)infection.However,few studies validated these concepts with high-defin...BACKGROUND Many studies evaluated magnification endoscopy(ME)to correlate changes on the gastric mucosal surface with Helicobacter pylori(H.pylori)infection.However,few studies validated these concepts with high-definition endoscopy without ME.AIM To access the association between mucosal surface pattern under near focus technology and H.pylori infection status in a western population.METHODS Cross-sectional study including all patients referred to routine upper endoscopy.Endoscopic exams were performed using standard high definition(S-HD)followed by near focus(NF-HD)examination.Presence of erythema,erosion,atrophy,and nodularity were recorded during S-HD,and surface mucosal pattern was classified using NF-HD in the gastric body.Biopsies were taken for rapid urease test and histology.RESULTS One hundred and eighty-seven patients were analyzed from August to November 2019.Of those,47(25.1%)were H.pylori+,and 42(22.5%)had a previous H.pylori treatment.In the examination with S-HD,erythema had the best sensitivity for H.pylori detection(80.9%).Exudate(99.3%),nodularity(97.1%),and atrophy(95.7%)demonstrated better specificity values,but with low sensitivity(6.4%-19.1%).On the other hand,the absence of erythema was strongly associated with H.pylori-(negative predictive value=92%).With NF-HD,56.2%of patients presented type 1 pattern(regular arrangement of collecting venules,RAC),and only 5.7%of RAC+patients were H.pylori+.The loss of RAC presented 87.2%sensitivity for H.pylori detection,70.7%specificity,50%positive predictive value,and 94.3%negative predictive value,indicating that loss of RAC was suboptimal to confirm H.pylori infection,but when RAC was seen,H.pylori infection was unlikely.CONCLUSION The presence of RAC at the NF-HD exam and the absence of erythema at S-HD were highly predictive of H.pylori negative status.On the other hand,the loss of RAC had a suboptimal correlation with the presence of H.pylori.展开更多
Objective: Probe-based confocal laser endomicroscopy(pCLE) technique may improve the diagnosis of gastric mucosal lesions allowing acquisition of high-resolution in vivo images at the cellular and microvascular levels...Objective: Probe-based confocal laser endomicroscopy(pCLE) technique may improve the diagnosis of gastric mucosal lesions allowing acquisition of high-resolution in vivo images at the cellular and microvascular levels. This study aims to evaluate the accuracy of pCLE for the differential diagnosis of non-neoplastic and neoplastic gastric lesions.Methods: Twenty gastric mucosal lesions from 10 patients were evaluated during endoscopic procedure and were examined by pCLE. Diagnostic pCLE was followed by biopsies or endoscopic resection of suspected lesions. A senior pathologist evaluated the specimens and was blinded to the pCLE results.Results: Patients' mean age was 68.3(range, 42-83) years and six were men. Thirteen suspicious flat or elevated lesions(classified as 0-Is, 0-IIa or 0-IIa + IIc) and seven pre-malignant lesions(atrophy and intestinal metaplasia)were evaluated. One patient was studied during his long-term follow-up after partial gastrectomy and presented severe atrophy, intestinal metaplasia, and xanthomas at the stump mucosa. The location of gastric lesions was in the body(n=10 lesions), the antrum(n=9) and the incisura angularis(n=1). All neoplastic lesions and all but one benign lesion were properly diagnosed by pCLE. pCLE incorrectly diagnosed one small antrum lesion as adenoma,however the final diagnosis was intestinal metaplasia. The final histological diagnosis was neoplastic in 9 and benign lesions in 11. In this small case series, pCLE accuracy was 95%(19/20 lesions).Conclusions: pCLE is accurate for real time histology of gastric lesions. pCLE may change the management of patients with gastric mucosal lesions, guiding biopsies and endoscopic resection, and avoiding further diagnostic workup or unnecessary therapy.展开更多
文摘AIM:To compare narrow-band imaging(NBI)without image magnification,and chromoendoscopy with Lugol's solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma(SCC)in patients with head and neck cancer.METHODS:This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas,S?o Paulo University Medical School,Brazil,between August 2006 and Feb-ruary 2007.Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed,and the discovered lesions were mapped,recorded and sent for biopsy.The results of the three methods were compared regarding sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood value and negative likelihood value.RESULTS:Of the 129 patients,nine(7%)were diagnosed with SCC,5 of which were in situ and 4 which were intramucosal.All carcinomas were detected through NBI and Lugol chromoendoscopy.Only 4 lesions were diagnosed through conventional examination,all of which were larger than 10 mm.CONCLUSION:NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC,and produces results comparable to those obtained with 2.5%Lugol chromoendoscopy.
文摘AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS: After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group).We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the MannWhitney test, χ 2 test, measurement of analysis of variance, and the κ statistic. RESULTS: The times to induction of sedation, recovery, and discharge were shorter in the propofolfentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolamfentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofolfentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION: Deep sedation occurred with propofolfentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.
基金Supported by department of Gastroenterology-Gastrointestinal Endoscopy Unit,So Paulo University School of Medicine
文摘AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.
文摘The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.
文摘Subepithelial lesions(SELs) in the upper gastrointestinal(GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound(EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor(GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration(EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions(size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.
文摘AIM: In order to characterize the qualitative and quantitative microorganisms in different sites of the lower digestive tract (LDT) in healthy volunteers, a specific technique was developed for collecting mucous of the distal ileum, colon and rectum. METHODS: A polyethylene tube was designed to go through the colonoscope channel with a No. 8 French tube. In order to avoid internal contamination, the distal extremity was protected with a membrane of microfilm after being sterilized in ethilene oxid. To facilitate the aspiration of a precise volume, its interior was coated with silicone. One hundred microlliter (0.1 mL) sample of mucous was collected and transferred into an Eppenddorff tube containing nine hundred microlliter (0.9 mL) of VMGA-3 (viable medium of Goteborg). This procedure was repeated at each site of the LDT with a new sterilized catheter. RESULTS: All sites revealed the "non pathogenic" anaerobic bacteria Veillonella sp (average 105 colony forming units/mL-CFU/mL), allowing to conclude an environment of low oxidation-reduction potential (redox) in the LDT. It was also characterized the presence of Klebisiella sp with significant statistical predominance (SSP) in the ileum. Enterobacter sp was found with SSP in the sigmoid colon, Bacteroides sp non-pigmented (npg) and E.coli with SSP in the sigmoid colon and rectum, Enterococcus sp and Lactobacillus sp with SSP in the rectum, all in a mean concentration of 105 CFU/mL. CONCLUSION: This procedure is feasible and efficient and can point out a similar distribution of the aerobic and anaerobic bacteria with the presence of biological markers of normal microbiota in the LDT.
文摘BACKGROUND Many studies evaluated magnification endoscopy(ME)to correlate changes on the gastric mucosal surface with Helicobacter pylori(H.pylori)infection.However,few studies validated these concepts with high-definition endoscopy without ME.AIM To access the association between mucosal surface pattern under near focus technology and H.pylori infection status in a western population.METHODS Cross-sectional study including all patients referred to routine upper endoscopy.Endoscopic exams were performed using standard high definition(S-HD)followed by near focus(NF-HD)examination.Presence of erythema,erosion,atrophy,and nodularity were recorded during S-HD,and surface mucosal pattern was classified using NF-HD in the gastric body.Biopsies were taken for rapid urease test and histology.RESULTS One hundred and eighty-seven patients were analyzed from August to November 2019.Of those,47(25.1%)were H.pylori+,and 42(22.5%)had a previous H.pylori treatment.In the examination with S-HD,erythema had the best sensitivity for H.pylori detection(80.9%).Exudate(99.3%),nodularity(97.1%),and atrophy(95.7%)demonstrated better specificity values,but with low sensitivity(6.4%-19.1%).On the other hand,the absence of erythema was strongly associated with H.pylori-(negative predictive value=92%).With NF-HD,56.2%of patients presented type 1 pattern(regular arrangement of collecting venules,RAC),and only 5.7%of RAC+patients were H.pylori+.The loss of RAC presented 87.2%sensitivity for H.pylori detection,70.7%specificity,50%positive predictive value,and 94.3%negative predictive value,indicating that loss of RAC was suboptimal to confirm H.pylori infection,but when RAC was seen,H.pylori infection was unlikely.CONCLUSION The presence of RAC at the NF-HD exam and the absence of erythema at S-HD were highly predictive of H.pylori negative status.On the other hand,the loss of RAC had a suboptimal correlation with the presence of H.pylori.
基金partially supported by FINEP(Financiadora de Estudos e Projetos)from Brazilian Ministry of Health
文摘Objective: Probe-based confocal laser endomicroscopy(pCLE) technique may improve the diagnosis of gastric mucosal lesions allowing acquisition of high-resolution in vivo images at the cellular and microvascular levels. This study aims to evaluate the accuracy of pCLE for the differential diagnosis of non-neoplastic and neoplastic gastric lesions.Methods: Twenty gastric mucosal lesions from 10 patients were evaluated during endoscopic procedure and were examined by pCLE. Diagnostic pCLE was followed by biopsies or endoscopic resection of suspected lesions. A senior pathologist evaluated the specimens and was blinded to the pCLE results.Results: Patients' mean age was 68.3(range, 42-83) years and six were men. Thirteen suspicious flat or elevated lesions(classified as 0-Is, 0-IIa or 0-IIa + IIc) and seven pre-malignant lesions(atrophy and intestinal metaplasia)were evaluated. One patient was studied during his long-term follow-up after partial gastrectomy and presented severe atrophy, intestinal metaplasia, and xanthomas at the stump mucosa. The location of gastric lesions was in the body(n=10 lesions), the antrum(n=9) and the incisura angularis(n=1). All neoplastic lesions and all but one benign lesion were properly diagnosed by pCLE. pCLE incorrectly diagnosed one small antrum lesion as adenoma,however the final diagnosis was intestinal metaplasia. The final histological diagnosis was neoplastic in 9 and benign lesions in 11. In this small case series, pCLE accuracy was 95%(19/20 lesions).Conclusions: pCLE is accurate for real time histology of gastric lesions. pCLE may change the management of patients with gastric mucosal lesions, guiding biopsies and endoscopic resection, and avoiding further diagnostic workup or unnecessary therapy.
