Jumbo Biopsy Research Articles

Jumbo biopsy is useful for the diagnosis of colonic prolapsing mucosal polyps with diverticulosis

We report here a case of multiple prolapsing mucosal polyps with diverticulosis in the sigmoid colon. A 52-year-old man was admitted to our hospital because of bloody diarrhea. Colonoscopy and barium enema showed multiple diverticula, markedly thickened mucosal folds and polypoid lesions with mucus on the top of them in the sigmoid colon. Endoscopic ultrasonography showed thickening of the mucosal and submucosal layers. Several endoscopic biopsy specimens were taken from the polypoid lesions. Histological examination revealed only chronic inflammatory cell infiltration. In order to obtain a definite diagnosis, we performed endoscopic jumbo biopsy for the polypoid lesions after obtaining informed consent. Histological examination revealed marked lymphocyte infiltration, hemosiderin deposits and fibromuscular obliteration in the lamina propria, features similar to those of mucosal prolapsing syndrome. After anti-diarrhetic treatment, clinical findings were improved. Thus, jumbo biopsy is useful for diagnosis and treatment of prolapsing mucosal polyps.

Accuracy of endoscopic optical coherence tomography in the detection of dysplasia in Barrett's esophagus: a prospective, double-blinded study

Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imaging technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett's epithelium, but this has not been established in a prospective blinded study. This study evaluated the accuracy of EOCT for the diagnosis and the exclusion of dysplasia in patients with Barrett's esophagus. A 2.4-mm diameter EOCT probe was modified for use with a cap-fitted, two-channel endoscope. Pairs of EOCT image streams and jumbo biopsy specimens were obtained. Endoscopy/EOCT procedures were performed by 4 endoscopists who separately reviewed the EOCT digital images for the absence or the presence of dysplasia (low grade, high grade, or cancer) for each biopsy specimen obtained. The endoscopists were blinded to the interpretation of the pathology. An experienced pathologist blinded to the endoscopic/EOCT findings evaluated each biopsy for the absence or the presence of dysplasia. The setting of the study was a major academic medical center. Adult patients with documented Barrett's esophagus greater than 2 cm were included in the study. The main outcome measurement was the accuracy of EOCT in the detection of dysplasia in patients with Barrett's esophagus. A total of 314 usable EOCT image stream/biopsy pairs were obtained in 33 patients. By using histology as the standard, the performance of EOCT was sensitivity, 68%; specificity, 82%; positive predictive value, 53%; negative predictive value, 89%; and diagnostic accuracy, 78%. Diagnostic accuracy for the 4 endoscopists ranged from 56% to 98%. Limitations of the study were the variability in endoscopists' accuracy rates, difficulty in real-time interpretation, and the need for refined criteria of dysplasia by EOCT imaging. The current EOCT system has an accuracy of 78% for the detection of dysplasia in patients with Barrett's esophagus. EOCT could be used to target biopsies to areas of Barrett's epithelium with a higher probability for the presence of dysplasia. However, further modifications, including increased resolution and identification of further potential OCT characteristics of dysplasia, are needed before EOCT can be used clinically.

A Randomized Controlled Trial of Ablation of Barrett’s Esophagus With Electrocautery vs. Argon Plasma Coagulation: Long-Term Results

Background: Many modalities have been used to ablate Barrett’s esophagus (BE) including multipolar electrocoagulation (MPEC), argon plasma coagulation (APC), laser, heater probe, etc. However, long-term results and comparative effectiveness are not known. Aim: Our aim was to compare efficacy of achieving complete reversal (ie, endoscopic and histologic) between MPEC and APC in BE patients. Methods: Patients with BE, 2–6 cm long underwent 24-hour pH test on PPI therapy (rabeprazole 20 mg BID). Twenty-four-hour pH was performed by placing probe 5-cm above LES, after at least 7 days of PPI therapy. Patients were then randomized by BE length to undergo ablation with either MPEC or APC every 4–8 weeks till endoscopic reversal or maximum of 6 treatment sessions. If the patient developed reflux symptoms or had documented erosive esophagitis, PPI dose was increased. To document BE reversal, esophagus was sprayed with Lugol’s solution, and 4 quadrant jumbo biopsies every 2 cm were obtained. Biopsies were stained with H&E/alcian blue to detect residual intestinal metaplasia. Fisher’s exact test and logistic regression were done to study effect of BE length, pH scores, hernia size, PPI dose, and ablation modality in achieving BE reversal. Results: Thirty-five BE patients have been followed-up for at least 2 years after endoscopic ablation, 16 treated with MPEC, and 19 with APC. Mean age was 61 years (32–84 years), 34 males. Mean length of BE was 3.7 ± 1.7 cm. Median total time pH <4 was 0.6% (range 0–29.9%); median upright and supine values were 0.7% and 0% respectively. Acid exposure normalized in 26 patients (74%) on rabeprazole 20 mg BID. BE completely reversed in 24 patients (69%); 75% with MPEC, and 63% with APC (P = .49). Mean number of sessions required was 3.8 in MPEC and 3.4 in APC group (P = .48). There was no significant difference in either treatment type (MPEC vs. APC), pH results, BE length, PPI dose, or hernia size between patients with and without complete reversal. No GI bleed or perforations noted; one patient developed an esophageal stricture treated successfully with 1 dilation. Conclusions: In BE patients treated with MPEC or APC in combination with aggressive acid suppression, there are no significant predictors associated with achieving complete reversal of BE including BE length, 24-hour pH, hiatus hernia size, and PPI dose. At long-term follow-up (2 years), complete reversal of BE can be maintained in ∼ 70% of patients irrespective of technique, ie, MPEC vs. APC. Continued surveillance is still indicated in post-ablative setting.

Randomized Controlled Study of a New InScope Multi-Clip Applier, Olympus QuickClip2, MPEC, Injection and Combination Therapy Comparing Hemostasis and Healing of Bleeding Canine Acute Gastric Ulcers

Purpose: There are no clinical and very few laboratory randomized studies comparing different hemoclips and other treatments for ulcer hemostasis. Our purposes were: 1) to compare deployment results of 3 clips/ulcer with InScope (INS) (Ethicon Endo-Surgery) vs. Olympus (OLY) QuickClip2's, 2) to evaluate long-term hemoclip retention rates, 3) to compare ulcer healing times after treatments and the influence of hemoclip retention on ulcer healing, and 4) to study safety of treatments. Methods: 6 adult mongrel dogs with prehepatic portal hypertension were heparinized. Gastric ulcers (GU's) were made with jumbo biopsy forceps (8 mm diameter, open) and randomized in pairs to 1 of 5 endoscopic treatments (INS, OLY, EPI, MPEC, EPI+MPEC) or control. Initial hemostasis was the 1° endpoint and closure of ulcers was a 2° endpoint for hemoclips. 3 hemoclips/ ulcer were placed. Animals were treated with oral PPI until ulcers healed. Failure of clip deployment on ulcers and time to initial hemostasis were recorded. At weekly F/U endoscopies, ulcer stigmata, size and healing; complications; and hemoclip retention were quantitated. Results: Initial failure of hemoclip deployment was 0% for INS and 7% for OLY. See Table 1 for initial results. The time required for 50% of ulcers to heal was significantly longer for MPEC (3 weeks) or EPI+MPEC (3.5 weeks) than EPI (2 weeks) or OLY, INS or control (1.5 weeks). There were no major complications.Table 1: Results to 4 wksConclusions: 1) Olympus and InScope hemoclips were similar in deployment times, success rates, and influence on ulcer healing. 2) More ulcer sites had InScope hemoclips retained after 1 month than OLY. 3) MPEC hemostasis was faster than either hemoclip. 4) Retained hemoclips across acute ulcers accelerated healing compared to MPEC, EPI, or combination. 5) No major complications resulted.Table 2: Ulcer Sites with ≥1 Hemoclips Retained in Long-Term F/U

A Large Pedunculated Rectal Carcinoid Tumor Resected by Endoscopic Snare Polypectomy

A 53 y/o asymptomatic black female with a history of HTN underwent a routine screening colonoscopy which revealed a 18mm pedunculated rectal polyp as well as a 10mm pedunculated transverse colon polyp. Both were removed by snare cautery. The rectal polyp was grossly atypical. It was pale, firm and nodular with irregular borders on a wide stalk. Pathology reported a rectal carcinoid tumor and a transverse colon tubular adenoma and. An endoscopic rectal ultrasound was performed three weeks later which revealed no invasion of the submucosa. Multiple jumbo biopsies were obtained from the polypectomy site all were negative for any residual carcinoid tumor tissue. Computed tomography of the chest, abdomen and pelvis were negative for metastasis. Discussion: Carcinoid tumors are derived from the neuroendocrine system. They have the capbility of secreting an array of biologically active agents. The incidence of carcinoid tumors has been estimated to be 8.4 per 100,000. 74% of carcinoid tumors are located in the gastrointestinal tract, the ileum, appendix and the rectum are the most common GI sites. The Bronchopulmonary system is responsible for the majority of the other sites. Grossly they are usually submucosal. They are usually yellow/tan or pale/gray secondary to a high lipid content, as well as firm and rubbery. Histologically they appear as nests, cords or rossettes of uniform round cells with rare mitotic figures. Immunohistochemically, they may be differentiated from other neuroendocrine tumors with chromogranins A, B, C, synaptophysin and enolase stains. They are best visualized endoscopicaly using EUS and by Somatostatin scintography, PET scans and CT scans. Tumors less than 1cm < 2% chance of mets, 1–1.9cm 10–15%, >2cm 60–80%. The overall survival rate of rectal carcinoid tumors is 72%. Their prognosis and treatment depend on a variety of factors including: location, size, degree of invasion and possibly by whether they are sessile or pedunculated. Pedunculated rectal carcinoid tumors are extremely rare. This may be the tenth reported case in medical literature. There have been recommendations regarding endoscpopic resection of flat, sessile rectal carcinoid tumors, however in our case of a pedunculated carcinoid tumor, more studies are needed to determine the prognosis and the most appropriate treatment.

Is EUS Superior to Standard Surveillance After Endoscopic Ablation for Barrett's Dysplasia?

Background: Barrett's esophagus (BE) patients with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) are at risk for disease recurrence in the esophagus or lymph nodes. Although used to select patients for PDT, the role of EUS for surveillance after PDT is unknown. We hypothesize that EUS is better than EGD and/or CT scan for surveillance of BE neoplasia after PDT. Methods: Consecutive patients with BE with HGD or carcinoma in situ treated with PDT using 2mg/kg porfimer sodium at light doses of 150-225 J/cm fiber length without a fiber centering device were followed with EUS, CT scan and EGD with 4 random jumbo biopsies every 1 cm at 3, 6, 9, 12, and then every 6 month intervals. Patients were excluded if they had less than 6 months of follow up and/or <2 EUS procedures. The outcome was detection of recurrent or residual carcinoma by any method. Results: Thirty of 97 patients did not meet inclusion criteria leaving 67 patients in the analysis (56 men and 11 women) with a median follow up of 16 months. Recurrent or residual adenocarcinoma was detected in 4 patients during follow up (17, 24, 30, and 36 months). Pre-PDT diagnosis in all four was HGD. EGD with random biopsies detected 2 patients, a third patient had a nodule seen on EGD with a biopsy revealing adenocarcinoma. EUS with EMR of the nodule confirmed T1 recurrence. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA confirmed adenocarcinoma in the lymph node. There were 2 deaths. One patient with progression of disease died of metastatic adenocarcinoma. The second patient died of unrelated causes. Overall rate of recurrent/persistent ACA after PDT in this series was 4/67 = 6%. EUS surveillance in 67 of these patients did not detect recurrent/persistent carcinoma that was otherwise detected by surveillance endoscopy using Seattle biopsy protocol and contrast enhanced computed tomography. Conclusions: While considered critical for the initial evaluation of patients being considered for endoscopic ablation therapy, EUS appears to have little role in the subsequent surveillance of these patients, unless discreet abnormalities are found on EGD or cross-sectional imaging.

A Randomized Controlled Trial of Ablation of Barrett's Esophagus With Electrocautery Vs. Argon Plasma Coagulation: Long Term Results

Many modalities have been used to ablate Barrett's esophagus (BE) including multipolar electrocoagulation(MPEC), argon plasma coagulation(APC), laser, heater probe, etc. However, long term results and comparative effectiveness are not known. Aim: Our aim was to compare efficacy of achieving complete reversal (i.e. endoscopic and histologic) between MPEC and APC in BE pts. Methods: Pts with BE, 2-6 cm long underwent 24 hr pH test on PPI therapy (rabeprazole 20 mg BID). 24 h pH was performed by placing probe 5 cm above LES, after at least 7 days of PPI therapy. Pts were then randomized by BE length to undergo ablation with either MPEC or APC every 4-8 weeks till endoscopic reversal or maximal of 6 treatment sessions. If pt developed reflux symptoms or had documented erosive esophagitis, PPI dose was increased. To document BE reversal, esophagus was sprayed with Lugol's solution and 4 quadrant jumbo biopsies every 2 cm were obtained. Biopsies were stained with H & E/alcian blue to detect residual intestinal metaplasia. Fisher's Exact test and logistic regression were done to study effect of BE length, pH scores, hernia size, PPI dose & ablation modality in achieving BE reversal. Results: 35 BE pts. have been followed for at least 2 yrs after endoscopic ablation, 16 treated with MPEC and 19 with APC. Mean age was 61 yrs (32-84 years), 34 males. Mean length of BE was 3.7 +/− 1.7 cm. Median total time pH <4 was 0.6% (range 0-29.9%); median upright & supine values were 0.7% and 0% respectively. Acid exposure normalized in 26 pts (74%) on rabeprazole 20mg BID. BE completely reversed in 24 pts (69%); 75% with MPEC and 63% with APC (p = 0.49). Mean no. of sessions required was 3.8 in MPEC and 3.4 in APC group (p = 0.48). There was no significant difference in either treatment type (MPEC vs. APC), pH results, BE length, PPI dose or hernia size between pts with and without complete reversal. No GI bleed or perforations noted; one pt developed an esophageal stricture treated successfully with 1 dilation. Conclusions: In BE pts. treated with MPEC or APC in combination with aggressive acid suppression, there are no significant predictors associated with achieving complete reversal of BE including BE length, 24 hr pH, hiatus hernia size and PPI dose. At long term f/u (2yrs), complete reversal of BE can be maintained in ~ 70% of pts irrespective of technique i.e. MPEC vs. APC. Continued surveillance is still indicated in post ablative setting. Funded by Eisai/Janssen.

Successful Eradication of Barrett's Mucosa With Argon Coagulation and Acid Suppression: Mid Term Results

Objectives: This report presents our clinical results of argon plasma coagulation (APC) and argon beam coagulation (ABC) in patients with Barrett's esophagus with and without low grade dysplasia (LGD). Methods: One hundred patients with Barrett's esophagus including 22 with LGD were treated using argon plasma coagulation (APC; ERBE), and argon beam coagulation (ABC; ConMed). Double dose proton pump inhibitor omeprazole, lansoprazole or esomeprazole were used for 2 months and the dose which is needed to control symptoms thereafter. Patients with Barrett's longer than 5 cm were treated in a semi-circumferential fashion in two sessions. The procedure is repeated every two months until complete endoscopic ablation is achieved. Jumbo biopsies were obtained and examined by a specialized GI pathologist. Patients were followed up for 4-70 months (mean 36 months). Results: Complete re-epithelialization was visualized at endoscopy in 92 patients after 1-4 procedures (mean 2.2). Partial eradication with squamous re-epithelialization was observed in 4 patients. Three patients lost follow up and one patient relapsed 2 years after complete eradication. Histological assessment showed Barrett's mucosa in apparently eradicated Barrett's in 4 patients and “buried Barrett's” in 2 patients. One patient who failed initial treatment developed high grade dysplasia 3 years later and underwent photodynamic therapy which resulted in complete ablation and squamous re-epithelialization. Histology from other patients revealed normal squamous epithelium with or without inflammation. Complications include two patients developed subcutaneous and mediastinal emphysema, bleeding requiring transfusion in one patient, fever in two patients, stricture requiring a single dilation in two patients, and pain requiring narcotic for up to one week in 20 patients. Conclusion: Argon coagulation with acid suppression can eradicate Barrett's mucosa with apparent squamous re-epithelialization in the majority of patients. Relapse is unlikely unless acid suppressive therapy is discontinued. Long term studies is needed to evaluate if such intervention prevent the neoplastic progression of Barrett's esophagus.

Yield of Tissue Sampling for Submucosal Lesions Evaluated by EUS: A Comparison Between Forceps Biopsies and Endoscopic Submucosal-Mucosal Resection

Background: Submucosal tumors (SMT) represent a heterogeneous group of histologic lesions located beneath the mucosal lining of the gastrointestinal tract. Most of these tumors lack distinct EUS features and, as such, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for SMT are currently lacking. The aim of this study was to prospectively determine the diagnostic yield of EUS-guided submucosal-mucosal resection and forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the gastrointestinal tract. Methods: Consecutive patients from April 2003 to December 2003 undergoing EUS evaluation of submucosal lesions were enrolled in the study. Those patients found to have submucosal lesions originating from the third endosonographic layer were identified. Biopsies were obtained using large capacity jumbo forceps. A total of four double passes (8 biopsies) were collected from each lesion using the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or with a cap-fitted endoscopic mucosal resection device. Results: Fifteen patients (40% male; mean age 54 years; range 26-81 years) with lesions limited to the submucosa were identified by EUS. All lesions underwent biopsy followed by endoscopic submucosal-mucosal resection. Final diagnoses: 3 lipomas; 3 pancreatic rests; 2 inflammatory fibroid polyps; 2 hemangiomas; 1 calcified fibrous nodule; 1 leiomyoma; 1 neurofibroma; 1 lymphangioma; 1 non-diagnostic. Anatomic distribution of the lesions included the stomach (12/15), esophagus (2/15) and rectum (1/15). Diagnostic yields were as follows: endoscopic submucosal-mucosal resection 13/15 (87%) versus jumbo biopsy 3/15 (20%) (p=0.009 by the McNemar test). There were 5 complications: 3 instances of bleeding (2 were successfully treated with immediate endoscopic intervention) and 2 episodes of abdominal pain. No hospital admissions, transfusions or provider visits were required. Conclusion: In the evaluation of submucosal lesions, endoscopic submucosal-mucosal resection has a significantly higher diagnostic yield than jumbo biopsy forceps using the bite-on-bite technique.

High Intensity Biopsy / High Frequency Ultrasound Probe Protocol May Accurately Identify Barrett's Patients Who Are Candidates For Local Ablative Therapy

Barrett's esophagus may lead to high grade dysplasia (HGD) and subsequent development of cancer. While esophagectomy is currently the management of choice for Barrett's patients with HGD or cancer, endoscopic therapy may be an option for patients with HGD or T1 cancers but not for patients with more advanced disease (T2 or greater). Screening regimens that could accurately differentiate between early (T1 or less) or advanced disease are needed to help identify patients that would be candidates for endoscopic therapy. We evaluated a screening protocol involving scanning with 20 MHz high-frequency ultrasound probe (HFUSP) followed by four-quadrant jumbo biopsies every one centimeter to determine: 1) the accuracy of high intensity biopsy protocol in the detection of HGD or esophageal cancer 2) staging accuracy of HFUSP 3) whether the combination of high intensity biopsy protocol and HFUSP could accurately select candidates for endoscopic therapy and 4) whether one or two centimeter distance between biopsies is required for accurate histological assessment. In patients who underwent an esophagectomy the pathological specimen was used as the gold standard. 21 patients (17 males, 4 females), mean age of 67 years (range 52 to 77) between September 1998 and June 2000 were studied. Mean length of Barrett's was 6.6 cm (range 0.5 cm to 18 cm). Mean follow up time was 8 months (range 1 to 20 months). 12 underwent esophagectomy, 9 were managed endoscopically or returned for close surveillance. The one-centimeter biopsy protocol detected lesions that a 2 cm protocol would have missed in 5 of the 18 patients studied (27%). In patients who underwent surgery, HFUSP accurately identified 11 of 12 (91%) as T1 or less. One patient was overstaged as T2 instead of T1 on pathology. No T2 tumors were understaged as T1 by HFUSP. Nodal staging was 100 % accurate. In patients with Barrett's esophagus, the combined 1 cm jumbo biopsy protocol with HFUSP may accurately identify patients with early disease who may be suitable candidates for local ablative therapy.

Granular Cell Tumor of the Esophagus: Report of a Pediatric Case and Literature Review

Granular Cell Tumor of the Esophagus: Report of a Pediatric Case and Literature Review

Yield of tissue sampling for submucosal lesions evaluated by EUS

<h2>Abstract</h2> <b>Background:</b> Evaluation of submucosal nodules or large gastric folds is a common indication for EUS. Establishing a tissue diagnosis is challenging because the yield of forceps biopsies is low. The aim of this study was to determine the diagnostic yield of EUS-guided endoscopic submucosal-mucosal resection and forceps biopsy for submucosal nodules and large gastric folds. <b>Methods:</b> Patients who underwent EUS from March 1997 through January 2002 for evaluation of submucosal nodules or large gastric folds were identified, and the procedure and pathology reports reviewed. Patients were included who underwent endoscopic submucosal-mucosal resection (n = 45) or large-capacity ("jumbo") biopsy (n = 36) of submucosal lesions (arising from third endosonographic layer) or large gastric folds. Endoscopic submucosal-mucosal resection was performed with an electrosurgical snare or with a cap-fitted endoscopic mucosal resection device. <b>Results:</b> Sixty-six patients (62% men; mean age, 61 years; range 27-80 years) underwent 69 EUS procedures to obtain tissue samples of subepithelial lesions. Diagnostic yields were as follows: endoscopic submucosal-mucosal resection 40/45 (89%; 95% CI [80%, 98%]), jumbo biopsy 15/36 (42%; 95% CI [26%, 58%]) (<i>p</i> < 0.001 by two-tailed Fisher exact test). There were 9 complications: 7 instances of bleeding (6 endoscopic submucosal-mucosal resection, 1 jumbo biopsy), 3 requiring hospitalization (2 endoscopic submucosal-mucosal resection, 1 jumbo biopsy) and 2 requiring transfusion; 1 chest pain and odynophagia (esophageal endoscopic submucosal-mucosal resection); and 1 oversedation (requiring administration of reversal agents). <b>Conclusions:</b> For submucosal lesions and large gastric folds, endoscopic submucosal-mucosal resection has a better diagnostic yield than the jumbo biopsy, but may have a higher complication rate. (Gastrointest Endosc 2003;57:68-72.)

Yield of tissue sampling for submucosal lesions evaluated by EUS

Background: Evaluation of submucosal nodules or large gastric folds is a common indication for EUS. Establishing a tissue diagnosis is challenging because the yield of forceps biopsies is low. The aim of this study was to determine the diagnostic yield of EUS-guided endoscopic submucosal-mucosal resection and forceps biopsy for submucosal nodules and large gastric folds. Methods: Patients who underwent EUS from March 1997 through January 2002 for evaluation of submucosal nodules or large gastric folds were identified, and the procedure and pathology reports reviewed. Patients were included who underwent endoscopic submucosal-mucosal resection (n = 45) or large-capacity (“jumbo”) biopsy (n = 36) of submucosal lesions (arising from third endosonographic layer) or large gastric folds. Endoscopic submucosal-mucosal resection was performed with an electrosurgical snare or with a cap-fitted endoscopic mucosal resection device. Results: Sixty-six patients (62% men; mean age, 61 years; range 27-80 years) underwent 69 EUS procedures to obtain tissue samples of subepithelial lesions. Diagnostic yields were as follows: endoscopic submucosal-mucosal resection 40/45 (89%; 95% CI [80%, 98%]), jumbo biopsy 15/36 (42%; 95% CI [26%, 58%]) ( p < 0.001 by two-tailed Fisher exact test). There were 9 complications: 7 instances of bleeding (6 endoscopic submucosal-mucosal resection, 1 jumbo biopsy), 3 requiring hospitalization (2 endoscopic submucosal-mucosal resection, 1 jumbo biopsy) and 2 requiring transfusion; 1 chest pain and odynophagia (esophageal endoscopic submucosal-mucosal resection); and 1 oversedation (requiring administration of reversal agents). Conclusions: For submucosal lesions and large gastric folds, endoscopic submucosal-mucosal resection has a better diagnostic yield than the jumbo biopsy, but may have a higher complication rate. (Gastrointest Endosc 2003;57:68-72.)

Evaluation of polypoid lesions in inflammatory bowel disease.

This article discusses patients with inflammatory bowel disease (IBD), a group which is at increased risk for colorectal carcinoma based on extent and duration of their disease. Patients with chronic IBD (at least 8-10 years duration) should be screened with colonoscopy every 1 to 2 years with multiple jumbo biopsies every 10 cm through the entire colon. Patients with sporadic adenomas can be followed after complete polypectomy, whereas patients with adenoma-like dysplasia-associated lesion or mass (DALMs) need increased surveillance. Patients with flat dysplasia or non adenoma-like DALMs are at high risk for progression and should undergo colectomy. The patients who have indeterminate lesions can be differentiated based on the endoscopic, histologic, and molecular features of the lesion. Long-term follow-up is necessary to determine the natural history of these lesions.

Endoscopic Mucosal Resection of the Stomach

A quantitative change of the enlargement of the biopsy specimen resulted in a qualitative change for endoscopy from only diagnosis to include therapy. This change of quality was also caused by another quantitative change of the size of detectable lesion, which was made smaller.

Sampling strategies for analysis of enterochromaffin-like cell changes in Zollinger-Ellison syndrome.

To investigate the optimum number of biopsy specimens to be obtained for enterochromaffin-like (ECL) cell monitoring in hypergastrinemic patients and ECL cell regional variations potentially influencing the results, qualitative ECL cell changes were assessed in 149 patients with Zollinger-Ellison syndrome using jumbo biopsy specimens and a systematic sampling procedure of 4 areas each from the lesser or greater curvature of the gastric body. Of 1,176 specimens examined, 1,101 were adequate. The correlation was excellent between different sites within the greater or lesser curvature. In contrast, a normal ECL cell pattern was more frequent in the lesser curvature, whereas linear hyperplasia was more frequent in the greater curvature. Dysplastic lesions and carcinoid tumors in endoscopically unremarkable mucosa were detected in 3.4% and 1.2% of biopsy specimens, respectively, and were equally distributed between the lesser and greater curvature. Their chances of being diagnosed were related to the number of specimens examined. Extensive sampling of both the lesser and greater curvature is recommended for early diagnosis of dysplastic and/or carcinoid lesions in patients at risk. In contrast, limited sampling in the greater curvature seems to be adequate in patients with no risk for carcinoid development.

Qualitative mapping of Barrett’s metaplasia: a prerequisite for intervention trials

Background: Barrett’s esophagus may present as a cellular mosaic with irregular longitudinal extensions of intestinal epithelium, spotty areas of dysplasia and other intermediate markers for cancer risk. It may not be possible to detect and reproducibly localize these findings with routine endoscopic biopsies. A more systematic biopsy protocol is necessary for chemopreventive studies to be feasible. Methods: Utilizing an adapted upper endoscope that allows accurate evaluation of distance from the incisors and rotatory position, chromoendoscopy with toluidine blue and systematic mapping (4 quadrant jumbo biopsies at 1 cm intervals) were performed twice on 18 patients with Barrett’s esophagus (second procedure 1 to 3 months after baseline study). All biopsy specimens were subjected to routine and immunohistochemical staining and flow cytometry to create baseline and follow-up maps for each patient. Eight of the 18 patients also underwent standard surveillance biopsies within 6 months of the systematic mapping procedures. Results: Epithelium type was reproducibly identified with 94% accuracy on second endoscopic maps. Ploidy, p53, and Ki-67 status were also reproducibly identified on second endoscopic maps (97%, 89%, and 85%, respectively). Dysplasia was found in 7 of 18 patients at similar sites at each mapping procedure (3 patients with high-grade dysplasia, 4 with low-grade dysplasia). Five of the patients who had dysplasia on mapping had also undergone standard surveillance. Low-grade dysplasia was missed in 2 of 3 patients and 1 patient with high-grade dysplasia had only low-grade dysplasia detected with standard biopsies. Conclusions: Utilizing a modified gastroscope and this methodology, we reliably located sites of dysplasia and other biomarkers within a field of Barrett’s esophagus. Patients had variable areas of dysplasia that were missed on standard endoscopic surveillance. (Gastrointest Endosc 1999;50:814-8.)

Jumbo biopsy forceps protocol still misses unsuspected cancer in Barrett's esophagus with high-grade dysplasia

Background: The optimal management of high-grade dysplasia in patients with Barrett's esophagus is controversial. The aim of this study was to assess the prevalence of unsuspected carcinoma at esophagectomy in patients with Barrett's esophagus with high-grade dysplasia after endoscopic surveillance with jumbo biopsy forceps compared with standard biopsy forceps. Methods: Twelve patients with high-grade dysplasia in Barrett's esophagus without gross or microscopic evidence of carcinoma underwent esophagectomy after preoperative endoscopy with 4-quadrant jumbo biopsies at 2-cm intervals. The findings in this group were compared with those in a group of patients with Barrett's esophagus who underwent esophagectomy for high-grade dysplasia after biopsies obtained at 2-cm intervals with standard biopsy forceps. Results: Unsuspected cancer was found in 4 of 12 (33%) patients in the jumbo biopsy group compared with 6 of 16 (38%) in the standard biopsy group ( p = NS). All 6 cancers in the standard biopsy group were intramucosal, whereas 2 were intramucosal and 2 were submucosal in the jumbo biopsy group. No patients in either group had lymph node metastases. Conclusions: Unsuspected cancer is found frequently in patients with Barrett's esophagus who are undergoing esophagectomy for high-grade dysplasia despite the use of a rigorous jumbo biopsy protocol. Esophageal resection is still indicated in appropriately selected patients with high-grade dysplasia until better markers of cancer risk are available. (Gastrointest Endosc 1999;49:170-6)

Randomized controlled studies of Injection Gold Probes compared with monotherapies for hemostasis of bleeding canine gastric ulcers

Background:There is a significant interest in combination therapy using endoscopic epinephrine injection and thermal coagulation for nonvariceal hemostasis. The purpose of the study was to compare the relative effectiveness, ease of use, and safety of new Injection Gold Probes to other hemostasis techniques in three randomized, controlled laboratory studies of bleeding canine gastric ulcers. Methods:Fifteen dogs with prehepatic portal hypertension were heparinized and bleeding gastric ulcers were induced with jumbo biopsy forceps. Three different prototypes of Injection Gold Probes were compared with monotherapy (thermal, electrocoagulation, or epinephrine injection alone), control, or combination therapy with separate injector and thermal probes. The treatment times, total number of pulses or injections, volume of epinephrine injected, and ease of applications were recorded. Gastric ulcer size, ulcer healing, and complications were evaluated at 1 and 4 weeks. Results:All endoscopic treatments were effective for acute hemostasis compared with control. Thermal coagulation alone was the fastest treatment to perform. The performance of the first Injection Gold Probe prototype was restricted by its small-gauge needle. The second and third Injection Gold Probe prototypes had a larger-gauge needle and irrigation channel which made them faster and easier to use than separate injection catheters and thermal probes. Conclusions:The advantages of Injection Gold Probes were the ability to irrigate, inject, and coagulate without probe removal. Combination therapy did not increase treatment-related complications compared with monotherapies. (Gastrointest Endosc 1998;48:598-605.)

Gastric outlet obstruction with benign endoscopic biopsy should be further explored for malignancy

Background: Gastric outlet obstruction is commonly considered a complication of peptic ulcer disease. Malignancy accounts for up to 39% of gastric outlet obstruction. The object of this study was to evaluate the reliability of endoscopic biopsies in excluding malignancy as the cause of gastric outlet obstruction. Methods: A retrospective study of 40 consecutive patients admitted with gastric outlet obstruction was conducted. Patient demographics, their use of H2-receptor antagonists or nonsteroidal anti-inflammatory drugs, and history of peptic ulcer disease were recorded. Histopathologic results of the endoscopic biopsy and surgical specimen were reviewed. The diagnosis based on the surgical specimen was considered the gold standard. Results: Sixteen patients (40%) had malignant gastric outlet obstruction. Seven patients had gastric adenocarcinoma and nine had extragastric tumors. The patients with malignant obstruction were significantly older (> 55 years) ( p = 0.03; odds ratio: 95% CI: 5.21 [1.05-23.49]). Gastric cancer patients had less frequently a history of peptic ulcer disease when compared with patients with benign gastric outlet obstruction ( p = 0.04; odds ratio: 95% CI: 5 [1.04-38.13]). Endoscopic biopsy to detect malignant obstruction had poor sensitivity (i.e., 37%) when compared with biopsies of the surgical specimen. In three of seven patients with gastric cancer (40%), repeated jumbo biopsies were negative for malignancy. Conclusion: Patients with gastric outlet obstruction who had endoscopic biopsies negative for cancer should be explored surgically before embarking on medical therapy. The surgical exploration is especially important in gastric outlet obstruction patients who are considered at high risk for malignancy, that is, those who are older and have no history of peptic ulcer disease. (Gastrointest Endosc 1998;48:497-500.)