Laser and multipolar electrocoagulation ablation of early Barrett's adenocarcinoma: long-term follow-up.

BACKGROUND: Endoscopic ablation of Barrett's esophagus, including associated dysplasia and adenocarcinoma, can be achieved by various techniques, but few long-term results are available. The aim of our study was ablation of intramucosal adenocarcinoma with a combination of Nd:YAG laser plus multipolar electrocoagulation. METHODS: Patients with documented Barrett's esophagus and adenocarcinoma who either had refused surgery or were poor candidates for surgery because of high risk were offered endoscopic therapy. Patients underwent therapy with Nd:YAG laser and multipolar electrocoagulation. They were treated with omeprazole (20 mg twice daily) as maintenance therapy. RESULTS: Six patients were enrolled in the study over a 7-year period. All were men with a mean age of 78.2 years. The mean length of Barrett's esophagus was 6.0 cm (range, 3 to 10 cm). Seventeen Nd:YAG laser (mean, 2.8/patient) and 20 multipolar electrocoagulation (mean, 3.3/patient) sessions were used during the study period. All patients had a complete initial response to therapy. One patient on chronic immunosuppressive medications had recurrence of the tumor after an initial complete response (36-month follow-up). Two patients have no evidence of Barrett's esophagus, and 3 patients have residual intestinal metaplasia on biopsy of an irregular appearing "neo" Z-line. Mean follow-up in this group is 3.4 years (range, 9 to 86 months). CONCLUSIONS: Laser photocoagulation and multipolar electrocoagulation can be successfully and safely used to ablate intramucosal adenocarcinoma in the setting of Barrett's esophagus. Patients remain functional with normal swallowing.

Delayed presentation of esophageal perforation as a result of overtube placement.

The first use of an overtube to assist endoscopy was described more than 20 years ago. Since then a number of uses of overtubes have been described, but relatively few complications have been reported. We report a case of esophageal perforation caused by overtube insertion during endoscopic band ligation of varices. This case is unique in that the patient presented 13 days after the original procedure, and it is the first reported case of esophageal injury involving the modified Bard overtube. The existing literature involving overtube injury is also reviewed.

Yield of routine endoscopy beyond the duodenal bulb.

The authors determined the clinical yield, endoscopic time, and patient tolerance of routine upper endoscopy beyond the duodenal bulb. From May through October 1994, all patients undergoing routine esophagogastroduodenoscopy (EGD) were recruited for study. Each procedure was timed from start to finish by the endoscopy nurse, and, in addition, the time of the postbulbar examination was recorded. The endoscopy nurse assessed the patient's comfort level when the endoscope was advanced into the duodenal bulb and again at the postbulbar region. A total of 250 EGDs were performed. There were 152 males and 98 females, with a mean age of 57.1 (range, 23-91) years. Indications for the procedure were as follows: gastroesophageal reflux disease symptoms 82, epigastric pain 64, dysphagia 46, Barrett's surveillance 25, anemia 23, other research study 16, and other 61. The mean time for the procedure was 11 min and 54 s, whereas the mean time for the postbulbar examination was 46.6 s. Patients tolerated endoscope insertion well both before and during examination of the postbulbar duodenum. The only postbulbar finding that affected clinical management was a postbulbar ulcer in a patient without other ulcers who was positive for Helicobacter pylori. Although routine endoscopic examination beyond the duodenal bulb involves minimal time and is well tolerated by patients, the yield of pathologic findings is low (3.6%) and the yield of findings that alter clinical management even lower (0.4%). In patients without prior GI surgery undergoing routine EGD for indications other than suspected small bowel pathology or active upper GI bleeding, examination of the postbulbar duodenum can be considered an elective part of the procedure.

Diagnostic and treatment guidelines for Helicobacter pylori.

Helicobacter pylori (H. pylori) has been implicated as the causative agent for most gastric and duodenal ulcers. Many patients who present to their primary care provider with dyspeptic symptoms have heard of this "stomach bacteria" and ask if they should be tested and treated for the infection. Prior to diagnosing the presence of the organism, it is essential to determine whether it is likely to be responsible for patients' symptoms. Most patients with ulcer-like symptoms do not have peptic ulcer disease. Moreover, the background prevalence of H. pylori may be high, depending on the age, race, and socioeconomic status of the patient population. Thus, antibiotic treatment to eradicate H. pylori may not provide symptom relief. H. pylori can currently be diagnosed by serology or by a number of techniques involving endoscopic biopsy. In the near future, urea breath testing will likely become the noninvasive method of choice for diagnosing and monitoring the success of treatment for H. pylori in the primary care setting. This article discusses the current issues related to diagnosis and treatment of H. pylori as they relate to the primary care provider and offers insight as to when specialty referrals should be considered.

The use of endoscopic ultrasonography in the evaluation and diagnosis of gastric lesions.

Endoscopic ultrasonography within the stomach can provide high resolution images of the gastric wall as well as adjacent lesions that cannot be achieved with other diagnostic modalities. Clinically important uses include the evaluation of submucosal tumors, thickened gastric folds, changes seen with portal hypertension, and the staging of gastric malignancy. Two basic principles should be considered when applying this modality in clinical practice. The first is that for any test to be considered truly indicated, the results should have some significant impact on management decisions and/or quality of life for the individual. The second is that endosonographic imaging is not a substitute for histology, but findings may have a direct impact on the need for and methods of obtaining biopsy material.

Plummer-Vinson syndrome. A case report and literature review.

The Plummer-Vinson syndrome is characterized by dysphagia, iron-deficiency anemia, and esophageal webs. The webs are best diagnosed by cineradiography. Iron repletion often improves the dysphagia, although some patients require esophageal dilatation or bougienage. The syndrome is associated with an increased incidence of postcricoid carcinoma, and surveillance endoscopy is recommended.

Endoscopic ultrasonography: current indications and applications.

Endoscopic ultrasonography is an exciting new field, with a rapidly expanding literature describing a wide variety of applications. Despite remarkable advances in the field, a number of crucial issues remain to be resolved. These include the limited availability of educational programs for training, enormous initial start up costs for centers related to the cost of equipment and the lack of interchangeability with processors, paucity of outcomes research studies, and technical limitations of the currently available devices. The aim of this article is to review the basic principles, instrumentation, applications, and potential problems related to endoscopic ultrasound and to attempt to define the realistic role for this tool in contemporary medical practice.

Technique of upper gastrointestinal endoscopy.

In order to obtain the greatest amount of diagnostic information from upper gastrointestinal endoscopy, it is necessary to have a thorough understanding of the methods of navigation, preparation of the equipment and patient, and accessory diagnostic procedures. By continually recalling these basic principles while performing upper endoscopic examinations, the goal of a complete, safe, and cost-effective examination will likely be obtained.