[Image-enhanced endoscopy and magnifying endoscopy for esophageal cancer]

Image diagnoses for esophageal cancer are progressing. With regard to endoscopic examination, chrome endoscopy using iodine have been performed so far to identify the range of lesion and to detect multiple primary cancers. In addition to that, endoscopic ultrasonography is used to diagnose the depth of tumor invasion and to identify lymph node metastasis. Recently, image-enhanced endoscopy (IEE) [e.g. Flexible spectral Imaging Color Enhancement (FICE), i-scan, Narrow Band Imaging (NBI), Autofluorescence imaging (AFI)] has developed. IEE is useful to detect superficial lesion, and is being utilized for diagnosing the tumor depth of invasion by using magnifying endoscopy( ME) together. In this literature, recent progress of endoscopic diagnosis, especially about IEE and ME, is reviewed. In addition to that, a way of endoscopic examination using IEE and ME is introduced.

Capsule endoscopy in patients refusing conventional endoscopy

Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies, allowing the non-invasive study of the entire mucosa. This has led, together with new technical advances, to the creation of two new models (PillCam ESO and PillCam Colon) for the study of esophageal and colonic diseases. These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts, because traditional endoscopy is often unpleasant and uncomfortable for the patient, can be painful, often requires moderate or deep sedation and is not without complications (hemorrhage, perforation, etc.). PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps, and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening, even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy. This article discusses the advantages of capsule endoscopy over conventional endoscopy, its current application possibilities and indications in routine clinical practice. In the various sections of the work, we assess the application of endoscopic capsule in different sections of the digestive tract (esophagus, stomach, and colon) and finally the potential role of panendoscopy with PillCam Colon.

Improved biopsy accuracy in Barrett’s esophagus with a transparent cap

AIM: To evaluate the efficacy of endoscopy with a transparent cap on biopsy positioning in Barrett’s esophagus (BE).

METHODS: One hundred and sixty-eight patients with suspected BE at endoscopy were enrolled in our study from November 2007 to December 2009 and divided into two groups: transparent cap group (n = 60) and control group (n = 108). Endoscopy with or without a transparent cap and subsequent biopsy of suspected lesions were performed by five experienced endoscopists in our hospital. In both groups, two biopsy specimens were taken from each patient, and the columnar epithelium or goblet cells in histological assessment were used as the diagnostic standard for BE.

RESULTS: In the transparent cap group, 41 cases were tongue type, while 17 and two cases were identified as island type and circumferential type, respectively. In the control group, 65 tongue-type cases were confirmed, with 38 island-type and five circumferential-type cases. Moreover, there was no significant difference with regard to the composition of endoscopic BE types in the two groups (P > 0.05). In the biopsy specimens, BE was detected in 50 cases in the transparent cap group (83.3%, 50/60), whereas the detection rate in the control group (69.4%, 75/108) was lower compared to that in the transparent cap group (P < 0.05). In addition, goblet cells were recognized in only eight cases (all with columnar epithelium) (8/60, 13.3%) in the transparent cap group, with 11 cases in the control group.

CONCLUSION: Transparent cap-fitted endoscopy can guide biopsy positioning in BE without other accompanying complications, thus increasing the detection rate of BE.

Esophageal stent fracture: Case report and review of the literature

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions. Self expanding metal stents (SEMS) are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions; however they have known complications of stent migration, stent occlusion, tumor ingrowth, stricture formation, reflux, bleeding and perforation amongst others. A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces. There have only been a handful of published case reports describing this problem. In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS, and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus. SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esophageal SEMS. It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment. Early recognition and prompt management may be able to prevent further problems.

[Stenting of the oesophagus and oesophageal anastomoses in the case of neoplastic stenosis]

The authors aimed to optimize the strategy and technology of regeneration of oesophagus patency and oesophageal anastomosis in a case of tumor stenosis. Results of endoscopic correction of neoplastic stenosis of the oesophagus were studied in 244 patients, the cases of oesophagocolic anastomosis--in 12 patients and outcomes of oesophagogastric--in 8, respectively. A protection of self-expandable stents is an effective method of regeneration of enteral feeding in patients with manifested dysphagia, which is specified by the growth of malignant tumor of the oesophagus or oesophageal anastomosis. A possibility of formation of broncho-esophageal communications limits the usage of silicone tubular and steel self-expandable stents with partial coating of a funnel by special indications: a disposition of proximal border of tumor stenosis less than 3 cm from esophageal--pharyngeal passage--for the first; a necessity of fast recovery of oesophagus patency in rigid stenosis and an impossible single-stage dilatation of constriction zone--for the second. An optimal device for oesophagus and anastomosis protection is a fiber-nitinol self-expandable stent with coating. The stents with antireflux valve should be used in the case of oesophagogastric passage lesions.

Acta from the EndoFLIP® Symposium

Laparoscopic fundoplication (LF) is a surgical treatment for gastroesophageal reflux disease (GERD) that has been performed for more than 20 years. High-volume centers of excellence report long-term success rates greater than 90% with LF. On the other hand, general population-based outcomes are reported to be markedly worse, leading to a nihilistic perception of the procedure on the part of the medical referral population. The lack of standardization of the technique and the lack of tools to calibrate objectively the repairs are probably among the causes of variability in the outcomes and may explain the decline in the number of LF procedures in recent years. The functional lumen imaging probe (EndoFLIP(®)) device is essentially a "smart bougie" in the form of a balloon catheter that measures shape and compliance of the gastroesophageal junction (GEJ) during surgery using impedance planimetry. With approximately 3 years of international experience gained with this tool, a symposium was convened in October 2012 in Strasbourg, France, with the aim of determining if intraoperative EndoFLIP use could provide standardization of surgical treatment of GERD through the understanding of physiological changes occurring to the GEJ during fundoplication. This article provides a brief history of the EndoFLIP system and reviews data previously published on the use of EndoFLIP to characterize the GEJ in normal subjects. It then summarizes the data from the 5 high-volume international sites with expert surgeons performing LF presented in Strasbourg to objectively profile the characteristics of a normal postoperative GEJ.

Endoscopic management of an esophagopericardial fistula after radiofrequency ablation for atrial fibrillation

A case is reported of a 76-year-old man with a past history of atrial fibrillation. A radiofrequency ablation procedure was suggested following several failed cardioversion attempts. However, an esophagopericardial fistula complicated the procedure. This life-threatening complication was successfully managed using both the placement of a covered esophageal stent and surgical pericardial and mediastinal drainage. In fact, no persisting fistula could be detected when the esophageal stent was removed seven weeks later. Atrioesophageal and esophagopericardial fistulas are two of the most severe complications associated with cardiological radiofrequency ablation procedures. They are responsible for majority of the deaths associated with this procedure. Despite the extremely high morbimortality associated with cardiothoracic surgery in such conditions, this treatment is the gold-standard for the management of such complications. This case report emphasizes the importance and efficacy of the endoscopic approach as part of a multidisciplinary management approach to this serious adverse event following radiofrequency ablation for atrial fibrillation.

Measurement of variceal pressure with a computerized endoscopic manometry: validation and effect of propranolol therapy in cirrhotic patients

Background and Purpose

Recently, we invented a computerized endoscopic balloon manometry (CEBM) to measure variceal pressure (VP) in cirrhotic patient. The purpose of this study was to evaluate the reliability and feasibility of this method, and whether this technique provided further information to pharmacological therapy.

Patients and Methods

VP measurements were performed in 83 cirrhotic patients and compared with HVPG as well as endoscopic bleeding risk parameters. Furthermore, VP was assessed before and during propranolol therapy in 30 patients without previous bleeding.

Results

VP measurements were successful in 96% (83/86) of all patients. Of the 83 patients, the VP correlated closely with the HVPG (P<0.001). The presence of red colour signs and the size of varices were strongly associated with VP. Patients with previous bleeding had higher VP than those who had not yet experienced bleeding. In univariate analysis, the level of VP, the size of varices, and red color signs predicted a higher risk of bleeding. The multiple logistic regression model revealed that VP was the major risk factor for bleeding. In 30 patients receiving propranolol, VP significantly decreased from 21.1±3.5 mmHg before therapy to 18.1±3.3 mmHg after 3 months and to 16.3±4.0 mmHg after 6 months. Comparing the mean decrease in VP with that in hepatic venous pressure gradient (HVPG), the decrease in VP was more obvious than HVPG response to propranolol.

Conclusions

This study showed that CEBM is safe and practical to assess VP in cirrhotic patient. It has the potential to be used as a clinical method to assess the risk of variceal bleeding and the effects of pharmacological therapy.

Trial registration

Effect of vasoactive drugs on esophageal variceal hemodynamics in patients with portal hypertension. Chinese Clinical Trial Registry –TRC-08000252.

Modular video endoscopy for in vivo cross-polarized and vital-dye fluorescence imaging of Barrett's-associated neoplasia

A modular video endoscope is developed and tested to allow imaging in different modalities. This system incorporates white light imaging (WLI), cross-polarized imaging (CPI), and vital-dye fluorescence imaging (VFI), using interchangeable filter modules. CPI and VFI are novel endoscopic modalities that probe mucosal features associated with Barrett's neoplasia. CPI enhances vasculature, while VFI enhances glandular architecture. In this pilot study, we demonstrate the integration of these modalities by imaging areas of Barrett's metaplasia and neoplasia in an esophagectomy specimen. We verify that those key image features are also observed during an in vivo surveillance procedure. CPI images demonstrate improved visualization of branching blood vessels associated with neoplasia. VFI images show glandular architecture with increased glandular effacement associated with neoplasia. Results suggests that important pathologic features seen in CPI and VFI are not visible during standard endoscopic white light imaging, and thus the modalities may be useful in future in vivo studies for discriminating neoplasia from Barrett's metaplasia. We further demonstrate that the integrated WLI/CPI/VFI endoscope is compatible with complementary high-resolution endomicroscopy techniques such as the high-resolution microendoscope, potentially enabling two-step ("red-flag" widefield plus confirmatory high-resolution imaging) protocols to be enhanced.

Color-matched and fluorescence-labeled esophagus phantom and its applications

We developed a stable, reproducible three-dimensional optical phantom for the evaluation of a wide-field endoscopic molecular imaging system. This phantom mimicked a human esophagus structure with flexibility to demonstrate body movements. At the same time, realistic visual appearance and diffuse spectral reflectance properties of the tissue were simulated by a color matching methodology. A photostable dye-in-polymer technology was applied to represent biomarker probed "hot-spot" locations. Furthermore, fluorescent target quantification of the phantom was demonstrated using a 1.2 mm ultrathin scanning fiber endoscope with concurrent fluorescence-reflectance imaging.

Endoscopic radiofrequency ablation of Barrett's esophagus

Recently, extensive data have been published about the safety and efficacy of endoscopic radiofrequency ablation (RFA) of Barrett's esophagus (BE) with early cancer and dysplasia as well as without dysplasia. RFA has been shown to be effective and safe. Circumferential RFA is delivered using the HALO(360+) Ablation System (Covidien, Inc., Mansfield, MA), which consists ofa high-power energy generator, a sizing balloon catheter, and a number of balloon-based ablation catheters with varying outer diameters. Focal RF energy is delivered using the HALO(90) or HALO(60) Ablation Systems (Covidien, Inc., Mansfield, MA), consisting of a radiofrequency energy generator and an endoscope-mounted electrode. Both RFA systems have official approval to be used in the United States, Europe, and other countries for the treatment of BE as well as in patients with gastric antral vascular ectasia and radiation proctopathy. With increasing widespread use of these systems, a full mastery of the equipment and therapeutic technique is essential to maximize eradication rates of BE while maintaining patient safety. A cost-effective patient selection and eradication protocol for RFA is essential to success with this technique in patients with BE. This article will discuss our experience with RFA treatment of BE using the HALO system for effective eradication of Barrett's dysplasia and early Barrett's cancer and review available data especially from the U.S. National Registry.

Risk of perforation using rigid oesophagoscopy in the distal part of oesophagus

INTRODUCTION

Endoscopic examination and treatment of disorders in the oesophagus have been a part of the otolaryngological specialty since the introduction of the rigid endoscope. Today, both flexible and rigid oesophagoscopy (RO) is used to that end. The aim of this study was to evaluate the safety of the RO.

MATERIAL AND METHODS

We conducted a retrospective cohort study of all ROs performed at a head & neck department in a Danish hospital in the 2003-2011-period. Perforation of the oesophageal wall was the primary endpoint. Secondary endpoints included: dental injury, mortality and, in case of a foreign body: location and successful removal.

RESULTS

A total of 483 ROs were performed. Four patients (0.8%) suffered perforation; three during removal of a foreign body in the lower part of the oesophagus and one as part of investigation for cancer. 46.2% of the procedures were performed to remove a foreign body and 32.7% as investigation for cancer. The majority of the foreign bodies were located in the superior part of the oesophagus and the objects were successfully removed in all but one case.

CONCLUSION

Our results are well within the range of previously published material. We recommend that the risk of serious complications is taken into consideration when choosing this modality. Furthermore, we believe that this risk increases in the distal part of the oesophagus and recommend that the use of the RO in this area is reserved as a last resort option.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

The effect of reactive atypia/inflammation on the laser-induced fluorescence diagnosis of non-dysplastic Barrett's esophagus

BACKGROUND AND OBJECTIVES

Differential Normalized Fluorescence (DNF) technique has been used to distinguish high-grade dysplasia from non-dysplastic Barrett's esophagus. This technology may assist gastroenterologists in targeting biopsies, reducing the number of biopsies using the standard protocol. In the presence of reactive atypia/inflammation, it becomes difficult for the pathologist to differentiate non-dysplastic Barrett's esophagus from Barrett's esophagus with low-grade dysplasia. Before DNF technique may be used to guide target biopsies, it is critical to know whether reactive atypia/inflammation in non-dysplastic Barrett's may result in false positives. This study was conducted to determine whether DNF technique is adversely affected by the presence of reactive atypia/inflammation in non-dysplastic Barrett's esophagus resulting in false positives.

STUDY DESIGN/MATERIALS AND METHODS

Four hundred ten-nanometer laser light was used to induce autofluorescence of Barrett's mucosa in 49 patients. The clinical study included 37 males and 12 females. This was a blinded retrospective data analysis study. A total of 303 spectra were collected and matched to non-dysplastic Barrett's biopsy results. One hundred seventy-five spectra were collected from areas with a pathology of non-dysplastic Barrett's esophagus with reactive atypia/inflammation. One hundred twenty-eight spectra were collected from areas with non-dysplastic Barrett's esophagus without reactive changes/inflammation. The spectra were analyzed using the DNF Index at 480 nm and classified as positive or negative using the threshold of -0.75 × 10(-3).

RESULTS

Using DNF technique, 92.6% of non-dysplastic samples with reactive atypia/inflammation were classified correctly (162/175). 92.2% of non-dysplastic samples without reactive atypia/inflammation were classified correctly (118/128). Comparing the ratios of false positives among the two sample groups, there was not a statistically significant difference between the two groups.

CONCLUSION

Using DNF technique for classification of non-dysplastic Barrett's mucosa does not result in false-positive readings due to reactive atypia/inflammation. Target biopsies guided by DNF technique may drastically reduce the number of pinch biopsies using the standard biopsy protocol.

[New technique for safe removal of impacted foreign bodies in the upper gastrointestinal tract using reusable variceal "cap" (cup, cap or cylinder)]

OBJECTIVES

The ingestion of a foreign body is one of the most common endoscopic emergencies. Foreign bodies in the upper gastrointestinal tract should be extracted as soon as possible to avoid serious complications such as perforation o bleeding. However, removals of foreign bodies with sharp edges are very difficult and can develop complications during their removal. Various devices have therefore been developed to prevent mucosal injury from the sharp edges during endoscopic extraction.

MATERIALS AND METHODS

We report a new technique for the successful foreign body extraction of upper digestive tract using the cap from six shooter variceal banding reused.

RESULTS

We present 17 cases (9 males and 8 females). The types of foreign bodies removed were: chicken bones (n:7), fish bones (n:3), denture prosthesis (n:2), food bolus (n:2), long pin (n:1), golden thumb tack (n: 1) and press-through package (n:1). There were no complications.

CONCLUSIONS

This new technique is safe and effective. Highlights its advantages: enhanced sight pharyngo esophageal junction, foreign bodies disimpact at that level, food bolus suck, avoid sharp object damage mucosal or scope and decrease time removal.