[Perforation risk in esophageal endoscopic mucosal resection with ligation: an experimental study with two ligator models]. / Riesgo de perforación en la mucosectomía esofágica con banda: estudio experimental con dos modelos de ligadores.

OBJECTIVE: endoscopic mucosal resection with ligation (EMRL) is considered an efficient, safe method for the treatment of some esophageal, gastric and colorectal tumors. We conducted this study using a porcine model in order to compare the safety of esophageal EMRL with two multiband ligation systems, since many centers only use these ligator models in EMRL (commercialized for varix ligation). METHODS: eight pigs were used, which were submitted to 23 esophageal resections without previous injection. Ten resections were conducted using the Six Shooter Saeed model, and 13 resections used the Speedband Superview Super 7 model. The technique was also compared by making random cuts either above or below the band. RESULTS: five perforations occurred, all of them using the Speedband model. This represents 38.5% of total in the Speedband model group. No perforation occurred when using the Six Shooter model (p = 0.046). On the contrary, no significant differences were found regarding frequency of perforation when cutting above or below the band. CONCLUSIONS: esophageal EMRL using the Speedband model without previous injection leads to perforation in a high percentage of cases in an experimental animal model. Further studies are required to find out whether a previous injection may increase the safety of this technique with this ligator model.

Incidence of tumoral pathology according to study using capsule endoscopy for patients with obscure gastrointestinal bleeding.

BACKGROUND: Capsule endoscopy has involved a significant advance in techniques for imaging of the small bowel. Its most frequent indication is for studying patients with obscure gastrointestinal bleeding (OGIB). Small bowel tumors are infrequent, representing only 1% to 3% of all malignant gastrointestinal tumors. This study aimed to assess retrospectively the occurrence and characteristics of tumoral pathology diagnosed by means of capsule endoscopy in patients with OGIB. METHODS: A retrospective review analyzed the first 320 patients submitted to capsule endoscopy because of OGIB (166 with obscure overt bleeding and 154 with obscure occult bleeding) at a single center. The patients with a tumor diagnosis were analyzed in terms of incidence, characteristics, and treatment of OGIB pathology. RESULTS: Tumor incidence was of 7.18% (23/320), with 65.2% of the cases supported with histologic confirmation (15/23). Obscure overt bleeding was the most frequent form of presentation, with the jejunum as the most frequent location (65.2%). For 16 patients, an intervention was conducted with a healing intent. Capsule endoscopy allowed the diagnosis of two cecal adenocarcinomas missed by colonoscopy. CONCLUSIONS: Small bowel tumors are not an infrequent cause of OGIB. Capsule endoscopy, even if it does not allow determination of the benign or malignant nature or the histologic type of the tumor, is a useful tool for the diagnosis and early management of these tumors.

Usefulness of endoscopic ultrasonography in the preoperative diagnosis of submucosal digestive tumours.

INTRODUCTION: The preoperative diagnosis of submucosal lesions in the gut may be complicated. Conventional endoscopy does not allow to clearly establishing a diagnosis, and does not adequately assess lesion size. Furthermore, endoscopic biopsy is usually not diagnostic. Cytology as performed by means of fine-needle puncture does not have enough sensitivity and specificity to be considered the gold standard in the diagnosis of these lesions. We will now assess the usefulness of endoscopic ultrasonography in the study of submucosal digestive tumors. MATERIALS AND METHODS: We have prospectively collected ultrasonographic studies from all the patients with submucosal tumors who were treated surgically. We assessed the sensitivity and specificity of this technique in the diagnosis of malignancy in said lesions, alongside factors that predict malignant behavior with the highest reliability. We also valued the reliability of ultrasound endoscopy in the assessment of lesion size and the wall layer where lesions are located. The results of histological studies were considered the gold standard. RESULTS: The average size of lesions as measured by ultrasound endoscopy was 37.42 mm, with no significant differences in surgical piece: 38.98 (p = 0.143). However, conventional endoscopy underestimates the size of lesions. Endoscopic ultrasonography was able to adequately establish the origin layer of lesions in all cases. Sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound endoscopy in the diagnosis of malignancy were 89.5, 90.9, 89.5, and 90.9%, respectively. In the univariate analysis, the ultrasonographic characteristics associated with a diagnosis of malignancy included presence of ulceration (p = 0.043), size above 4 cm (p = 0.049), irregular edges of lesion (p = 0.0001), a heterogeneous ultrasonographic pattern (p = 0.002), and the presence of cystic areas above 2 mm (p = 0.012). In the multivariate analysis, the last three factors were considered independent predictive factors for malignancy. CONCLUSIONS: Endoscopic ultrasonography has a great sensitivity and specificity in the diagnosis of malignancy regarding submucosal lesions. The irregularity of lesion borders, a heterogeneous ultrasonographic pattern, and the presence of cystic areas above 2 mm in size were considered independent predictive factors for malignancy.

The value of abdominal ultrasound in the diagnosis of colon cancer.

INTRODUCTION: Colon cancer is one of the main causes of cancer death. Diagnosis requires the examination of the entire large bowel by means of radiological or endoscopic techniques. Many patients suspect of colon cancer are referred for colonoscopy but nevertheless this suspicion is not confirmed after endoscopic examination. The objective of this study is the evaluation of the reliability of abdominal ultrasound in the diagnosis of these tumors. MATERIAL AND METHOD: We selected patients suspect of colon cancer referred to the endoscopy unit for a colonoscopy. An abdominal ultrasound was carried out on all patients prior to the endoscopy. Considering the endoscopic examination as a gold standard, the sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ultrasonography were evaluated. Likewise, a series of analytical and clinical parameters were evaluated, in an attempt to establish associated factors of a colon cancer. The statistical analysis was carried out by means of the statistical package SPSS 12.0 for Windows. RESULTS: 145 patients were included in the study (56.6% males) with an average 66.72 years of age (22-89). A cancer was diagnosed in 42 cases (28.9%). In the diagnosis of colon cancer, abdominal ultrasound presents a sensitivity of 79.06%, a specificity of 92.15%, a PPV and a NPV of 80.9% and of 91.2%, respectively. Excluding from the analysis lesions of the rectal ampulla, which cannot be adequately evaluated by means of ultrasound, the figures for sensitivity, specificity, PPV and NPV increase to 91.8, 92.1, 80.9 and 96.9% respectively. The univariate analysis showed that an age over 65 years and the presence of microcytosis are associated to a greater risk of colon cancer while after multivariate analysis only the presence of microcytosis resulted to be an independent predictive factor of cancer. CONCLUSIONS: Abdominal ultrasound presents high sensitivity, specificity, PPV and NPV in the diagnosis of colon cancer. The combination of an ultrasonography and a rectoscopy permits us to rule out the presence of a colorectal carcinoma. In patients with microcytosis of 65 years and over, if there is strong clinical suspicion, a negative ultrasound may not be sufficient to rule out a colorectal neoplasia.

Obscure gastrointestinal bleeding: a complication of radiation enteritis diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a common disorder and may account for as many as 5% of all gastrointestinal hemorrhages. It is often caused by lesions in the small intestine, which were very complicated to examine prior to the advent of wireless capsule endoscopy. Here we present the case of a 31-year-old woman with obscure gastrointestinal bleeding as a complication of radiation enteritis, which was diagnosed only after she underwent an examination with wireless capsule endoscopy. This technique has proven to be far superior to other radiographic and endoscopic methods in diagnosing obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Recurrent Dieulafoy's disease with surgical management: diagnosis by endoscopic ultrasonography.

Dieulafoy's disease is an uncommon but potentially significant cause of gastrointestinal bleeding caused by a large-caliber arterial vessel in the submucosa, which causes erosion and debilitation of the surrounding mucosa and may lead to massive gastrointestinal bleeding. Since endoscopy may prove insufficient, echoendoscopy may help in the diagnosis of this condition. Echoendoscopy may also help improve endoscopic management using mechanical techniques (hemoclips or band ligation) or a combination of thermal techniques and injection sclerotherapy, since this allows an accurate localization of the submucosal vessel. We present a case illustrating this approach by endoscopic ultrasonography, and describe the morphological substrate of this condition.

Jejunal leiomyosarcoma, a rare cause of obscure gastrointestinal bleeding diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a relatively frequent disorder and may account for as many as 5% of all cases of gastrointestinal bleeding. The etiology of these hemorrhages may be attributed to lesions in the small intestine, which may not show up in radiologic studies, located in areas inaccessible to conventional endoscopy. The case of a 50-year-old patient admitted to the hospital on two occasions for gastrointestinal bleeding requiring blood transfusions is reported. On the first occasion, the bleeding was thought to be caused by a duodenal ulcer because no other lesions prone to bleeding were found. At the next admission for recurrent bleeding, the ulcer was found to have healed and thus was ruled out as the cause. Wireless capsule endoscopy detected an ulcerated tumor invading the submucosa of the jejunum. The pathologic diagnosis was low-grade leiomyosarcoma. Wireless capsule endoscopy has proved to be far superior to other radiologic and endoscopic techniques for the diagnosis of obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Liver transplantation in patients with hepatocellular carcinoma: factors implicated in tumor relapse.

INTRODUCTION: Liver segmental resection and liver transplantation are both treatments intended for healing liver cancer. An adequate selection of patients eligible for transplantation is crucial, since organs available for transplants are usually scarce. For this reason, awareness of the prognostic factors of relapse is of great importance. We present a comprehensive review of our series in order to better understand these prognostic factors. MATERIAL AND METHODS: We revised the cases of patients with hepatocellular carcinoma who underwent liver transplantation during the period 1994-2000, and present a detailed analysis of a series of variables which may be probably implicated in the appearance of relapse and which have an effect on survival. RESULTS: After a mean follow-up of 33 months, the mortality rate was 27.5% and relapse occurred in 18.75% of cases. No history of alcohol abuse, the number and size of the nodules, the presence of macro and microscopic vascular invasion, and pTNM stage T4 were all factors associated with a significantly increased risk of relapse (p<0.05). These factors and positive HCV were associated to decreased survival. After a multivariate analysis, the size of the nodules and the presence of macroscopic vascular invasion were considered the only independent risk factors for tumor relapse and post-transplantation relapse and mortality, respectively. CONCLUSIONS: Macroscopic vascular invasion and tumor nodules larger than 5 cm are both independent risk factors of tumor relapse after transplantation. Nevertheless, only macroscopic vascular invasion seems to have a significant effect on survival.

Indication and results of endoscopic management of sigmoid volvulus.

INTRODUCTIONS: sigmoid volvulus is a relatively common cause of intestinal obstruction, particularly in the elderly and in patients with debilitating conditions. As the risks associated with surgical treatment of the sigmoid volvulus are in many cases too high, conservative (endoscopic) management is an option to be considered. MATERIAL AND METHODS: all emergency lower gastrointestinal endoscopies performed between January 1, 1996 and December 31, 2001 were review and, among these, the cases of diagnosis of sigmoid volvulus were selected. The results of the endoscopic management, percentage of recurrence, mortality rate, complications, surgical procedures etc were evaluated in the select cases. RESULTS: lower gastrointestinal endoscopy was diagnostic in all cases. Endoscopic management showed and overall efficacy of 87.5%. recurrence appeared in approximately 57% of the cases. Successful treatment was accomplished for the first episode in 25% of the cases. In case of recurrence, endoscopic management could be performed again with similar efficacy and safety. CONCLUSIONS: endoscopic reduction is a safe and successful technique for the management of emergency sigmoid volvulus, provided vascular compromise in the intestinal wall is ruled out. As recurrence is frequent, elective definitive surgery could be a treatment to consider. Endoscopic management could be the only choice treatment in the case of patients not it for surgery due to the very important risks associated with it their cases.

Treatment of achalasia with the Witzel dilator: a prospective randomized study of two methods.

BACKGROUND AND STUDY AIMS: Several studies have shown that the use of the Witzel dilator is an effective and safe treatment for achalasia. However, the optimal values for pressure, number of dilations, and duration of application have not yet been established. The aim of this study was to determine these three parameters. PATIENTS AND METHODS: 43 patients with a diagnosis of achalasia (based on clinical, radiological, manometric and endoscopic evaluation) were randomly allocated to one of two treatment groups. Patients in group A (n=21) underwent three consecutive 1-minute dilations per session at 1-minute intervals, at 200 mmHg for the first dilation and 300 mmHg for the second and third. In group B patients (n=22) only one dilation was done, at 200 mmHg for 2 minutes. Before and after treatment, the clinical score, the maximum esophageal diameter (obtained using barium contrast studies) and the basal pressure of the lower esophageal sphincter were evaluated in each patient. The need for further treatment and the presence of complications were also determined. RESULTS: Both methods led to clinical, radiological, and manometric benefits. No differences were observed between the methods (satisfactory results in 86%; one perforation in each group). Six patients underwent operation; five for an incomplete response and one for a perforation. CONCLUSIONS: There were no differences between the two groups investigated, suggesting that only one 2-minute dilation at 200 mmHg is sufficient.

Mean pressure obtained by modified rapid pull-through technique used to assess lower esophageal sphincter function.

Lower esophageal sphincter pressure, length of sphincter, and contraction of the crural diaphragm are determinants of esophageal function. Mean pressure manometrics in modified rapid pull-through reflects these three factors. Reproducibility and interobserver variability were studied to assess this method's efficacy and were compared with the maximum expiratory pressure in station pull-through in 44 individuals divided into three groups: achalasia, gastroesophageal reflux, and healthy volunteers. Mean pressure in rapid pull-through showed high reproducibility, no significant differences (14.4 +/- 8.4 vs 12.6 +/- 8.2 mm Hg) between two measurements, and a high correlation coefficient (r = 0.9). Interobserver variability was lower than that seen for maximum expiratory pressure (P < 0.001). Mean pressure was lower than maximum expiratory pressure in patients with achalasia (21.1 +/- 7 vs 30.7 +/- 8.6 mm Hg). Both methods showed identical sensitivity to establish a hypotensive sphincter in patients with reflux (73%). We think that mean pressure obtained by rapid pull-through is a good methodology to assess lower esophageal sphincter competence. It is rapid, simple, shows good reproducibility and low interobserver variability, and is clinically valid.

Early-stage gastric MALT lymphomas: eradication of H. pylori and outcome.

BACKGROUNDS AND OBJECTIVE: Lymphomas of mucosa-associated lymphoid tissue are special because of their indolent course. Low-grade early-stage tumors resolve after Helicobacter pylori (HP) eradication in a high percentage of cases. The aim of this study was to evaluate this regression in our patients with EI1 stage-low-grade B gastric lymphomas after eradication therapy since the introduction of echoendoscopic examinations in the Gastroenterology Department of 'Juan Canalejo' Hospital. MATERIAL AND METHODS: A retrospective study of all cases of low-grade MALT gastric lymphomas in EI1 stage, diagnosed by histological and echoendoscopic examination, from June 1997 to December 2001. After eradication of HP with triple therapy, patients have been followed-up with endoscopic examinations at 2, 3 and 6 months, and yearly afterwards. RESULTS: There were 14 patients in this period with low-grade EI1 stage gastric MALT B cell lymphoma. The median age was 65 years, and 57% were females. HP was eradicated in all cases with first- or second-line (2 patients) antibiotic treatment. Complete remission was observed in 10 patients (71.4%) in a median time of 4.5 months. The other 4 patients needed chemotherapy because of non-remission or early relapse, and also as initial treatment. Complete remission was also obtained in these patients. Only 9 patients have been followed up in our unit for a median time of 20 months, period after which all remain free of disease. CONCLUSIONS: Low-grade early-stage MALT gastric B-cell lymphomas have a high rate of response to HP eradication therapy. Echoendoscopic staging helps in distinguishing the group of patients who will benefit from conservative treatment. These patients must be followed up as it remains unclear whether remission is maintained in the long term, and to know what factors could be associated with lymphoma relapse.