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1.
Lancet Oncol ; 23(2): 270-278, 2022 02.
Article in English | MEDLINE | ID: covidwho-1616869

ABSTRACT

BACKGROUND: Endoscopic surveillance is recommended for patients with Barrett's oesophagus because, although the progression risk is low, endoscopic intervention is highly effective for high-grade dysplasia and cancer. However, repeated endoscopy has associated harms and access has been limited during the COVID-19 pandemic. We aimed to evaluate the role of a non-endoscopic device (Cytosponge) coupled with laboratory biomarkers and clinical factors to prioritise endoscopy for Barrett's oesophagus. METHODS: We first conducted a retrospective, multicentre, cross-sectional study in patients older than 18 years who were having endoscopic surveillance for Barrett's oesophagus (with intestinal metaplasia confirmed by TFF3 and a minimum Barrett's segment length of 1 cm [circumferential or tongues by the Prague C and M criteria]). All patients had received the Cytosponge and confirmatory endoscopy during the BEST2 (ISRCTN12730505) and BEST3 (ISRCTN68382401) clinical trials, from July 7, 2011, to April 1, 2019 (UK Clinical Research Network Study Portfolio 9461). Participants were divided into training (n=557) and validation (n=334) cohorts to identify optimal risk groups. The biomarkers evaluated were overexpression of p53, cellular atypia, and 17 clinical demographic variables. Endoscopic biopsy diagnosis of high-grade dysplasia or cancer was the primary endpoint. Clinical feasibility of a decision tree for Cytosponge triage was evaluated in a real-world prospective cohort from Aug 27, 2020 (DELTA; ISRCTN91655550; n=223), in response to COVID-19 and the need to provide an alternative to endoscopic surveillance. FINDINGS: The prevalence of high-grade dysplasia or cancer determined by the current gold standard of endoscopic biopsy was 17% (92 of 557 patients) in the training cohort and 10% (35 of 344) in the validation cohort. From the new biomarker analysis, three risk groups were identified: high risk, defined as atypia or p53 overexpression or both on Cytosponge; moderate risk, defined by the presence of a clinical risk factor (age, sex, and segment length); and low risk, defined as Cytosponge-negative and no clinical risk factors. The risk of high-grade dysplasia or intramucosal cancer in the high-risk group was 52% (68 of 132 patients) in the training cohort and 41% (31 of 75) in the validation cohort, compared with 2% (five of 210) and 1% (two of 185) in the low-risk group, respectively. In the real-world setting, Cytosponge results prospectively identified 39 (17%) of 223 patients as high risk (atypia or p53 overexpression, or both) requiring endoscopy, among whom the positive predictive value was 31% (12 of 39 patients) for high-grade dysplasia or intramucosal cancer and 44% (17 of 39) for any grade of dysplasia. INTERPRETATION: Cytosponge atypia, p53 overexpression, and clinical risk factors (age, sex, and segment length) could be used to prioritise patients for endoscopy. Further investigation could validate their use in clinical practice and lead to a substantial reduction in endoscopy procedures compared with current surveillance pathways. FUNDING: Medical Research Council, Cancer Research UK, Innovate UK.


Subject(s)
Adenocarcinoma/pathology , Barrett Esophagus/pathology , COVID-19 , Esophageal Neoplasms/pathology , Patient Selection , Watchful Waiting/methods , Adenocarcinoma/diagnostic imaging , Adenocarcinoma/metabolism , Aged , Barrett Esophagus/diagnostic imaging , Barrett Esophagus/metabolism , Barrett Esophagus/therapy , Biomarkers/metabolism , COVID-19/prevention & control , Clinical Decision-Making , Clinical Trials as Topic , Cross-Sectional Studies , Decision Trees , Disease Progression , Esophageal Neoplasms/diagnostic imaging , Esophageal Neoplasms/metabolism , Esophagoscopy , Feasibility Studies , Female , Humans , Male , Middle Aged , Pilot Projects , Prospective Studies , Retrospective Studies , Risk Assessment , Risk Factors , SARS-CoV-2 , Trefoil Factor-3/metabolism , Tumor Suppressor Protein p53/metabolism
3.
Surg Endosc ; 35(9): 5124-5129, 2021 09.
Article in English | MEDLINE | ID: covidwho-1453744

ABSTRACT

BACKGROUND: Flexible endoscopy allows use of the vessel-tissue sealer Ligasure™ (Covidien, Massachusetts, USA) to perform diverticulotomy. Few studies have used this endoscopic approach in the uncommon disorder Zenker's diverticulum. The aim of the present study was to evaluate the effectiveness and safety of flexible endoscopy treatment assisted by Ligasure™. METHODS: The single-center prospective and descriptive study included patients treated by flexible endoscopy using Ligasure™ for resection of Zenker's diverticulum. Consecutive patients were included from March 2009 to April 2018. Patients were censored until the end of follow-up or death. Complications, symptoms before treatment, type of sedation, and number of interventions needed to resolve Zenker's diverticulum were analyzed. Bleeding complications were considered when a case required a second endoscopy. RESULTS: A total of 46 symptomatic patients with Zenker's diverticulum were included in the final analysis (41.3% women, median age of 73.7 ± 11 years). The median follow-up period was 37.21 ± 28 months. Of all cases, 58.7% were considered small (< 3 cm). Solid or semi-solid food-related dysphagia was present in 55.6% of patients previously to the procedure. The technique was successful in a single procedure in 78.3% of cases. However, the success rate increased to 89.1% with a second procedure, and we had a complication rate of 4.3% with this technique. Most patients (79.66%) were managed as out-patients or with short (< 24 h) admission. CONCLUSION: In this large case series, treatment of Zenker's diverticulum based on flexible endoscopy assisted by Ligasure™ was a safe and effective procedure with a high success rate in a few endoscopy sessions and low complication rate.


Subject(s)
Deglutition Disorders , Zenker Diverticulum , Aged , Aged, 80 and over , Endoscopes , Endoscopy , Esophagoscopy , Female , Humans , Male , Middle Aged , Prospective Studies , Retrospective Studies , Treatment Outcome , Zenker Diverticulum/surgery
4.
Gut ; 71(5): 871-878, 2022 May.
Article in English | MEDLINE | ID: covidwho-1288454

ABSTRACT

OBJECTIVE: To determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events. DESIGN: A prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient's mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject. RESULTS: Patients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L-1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L-1). Aerosol recording during OGD showed an average particle number concentration of 595 L-1 with a wide range (3-4320 L-1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient's reference voluntary coughs (11 710 vs 2320 L-1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered. CONCLUSION: Coughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.


Subject(s)
COVID-19 , Cough , Endoscopy, Gastrointestinal/adverse effects , Adult , Aerosols , Cough/etiology , Duodenoscopy , Esophagoscopy , Gastroscopy , Humans , Particle Size , Prospective Studies
8.
Otolaryngol Head Neck Surg ; 163(3): 455-458, 2020 09.
Article in English | MEDLINE | ID: covidwho-378048

ABSTRACT

With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a specialty faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol-generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.


Subject(s)
Coronavirus Infections/epidemiology , Deglutition Disorders/diagnosis , Infection Control/standards , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , Barium Sulfate/administration & dosage , Betacoronavirus , COVID-19 , Coronavirus Infections/diagnosis , Endoscopy , Esophagoscopy , Humans , Pandemics , Pneumonia, Viral/diagnosis , SARS-CoV-2
9.
Head Neck ; 42(7): 1491-1496, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-291715

ABSTRACT

The global pandemic of 2019 novel coronavirus disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the health care system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than severe acute respiratory syndrome (SARS) in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and health care personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the noninstrumental swallowing evaluation, appropriate use of personal protective equipment (PPE), and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.


Subject(s)
Betacoronavirus , Coronavirus Infections , Deglutition Disorders/diagnosis , Head and Neck Neoplasms/complications , Infection Control/organization & administration , Pandemics , Pneumonia, Viral , Air Filters , Barium Sulfate , COVID-19 , Contrast Media , Deglutition Disorders/etiology , Environmental Exposure/prevention & control , Esophagoscopy , Fluoroscopy , Humans , Occupational Exposure/prevention & control , Personal Protective Equipment , Quarantine , SARS-CoV-2 , Telemedicine , Video Recording
10.
Head Neck ; 42(7): 1634-1637, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-141707

ABSTRACT

BACKGROUND: The United States now has the highest death toll due to COVID-19. Many otolaryngology procedures, including laryngoscopy, bronchoscopy, and esophagoscopy, place otolaryngologists at increased risk of coronavirus transmission due to close contact with respiratory droplets and aerosolization from the procedure. The aim of this study is to provide an overview of guidelines on how to perform these procedures during the coronavirus pandemic. METHODS: Literature review was performed. Articles citing laryngoscopy, bronchoscopy, esophagoscopy use with regard to COVID-19 were included. RESULTS: Laryngoscopy, bronchoscopy, and esophagoscopy are all used in both emergent and elective situations. Understanding the risk stratification of cases and the varied necessity of personal protective equipment is important in protecting patients and health care workers. CONCLUSIONS: Summary guidelines based on the literature available at this time are presented in order to decrease transmission of the virus and protect those involved.


Subject(s)
Betacoronavirus , Bronchoscopy , Coronavirus Infections/epidemiology , Esophagoscopy , Laryngoscopy , Pneumonia, Viral/epidemiology , Air Pollutants, Occupational , COVID-19 , Coronavirus Infections/diagnosis , Critical Pathways , Humans , Infection Control/standards , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Occupational Exposure/prevention & control , Pandemics , Personal Protective Equipment/standards , Pneumonia, Viral/diagnosis , SARS-CoV-2 , Triage
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