ABSTRACT: Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation.
To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE.
A prospective, randomized, controlled trial was conducted between February 2008 and February 2009.
Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured.
Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172).
Single-blind study; sample size.
Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
Gastrointestinal endoscopy 01/2011; 73(1):45-51, 51.e1. · 6.71 Impact Factor
ABSTRACT: The results of variceal band ligation (VBL) in patients with advanced liver disease are unknown. Cyanoacrylate injection (CI) might have a better outcome than VBL in the treatment of esophageal varices (EV) in these patients.
To compare VBL and CI in the treatment of EV in patients with advanced liver disease.
Thirty-eight patients with medium or large EV and Child-Pugh index of at least eight were randomized into two groups: VBL (n=20) and CI (n=18). The patients were followed-up for at least 6 months after the end of treatment. Main outcomes were eradication, bleeding, mortality, complication, and recurrence rates.
Variceal eradication rates were similar in the VBL and CI groups (90 vs. 72%, P=0.39). Mean number of sessions until eradication was 3.17 and 3, respectively. Bleeding episodes until eradication were equally observed in both groups (P=0.17). Mortality (55 vs. 56%, P=0.52) and major complication rates (5 and 17%, P=0.32) were similar. Chest pain with dysphagia was more frequent in the CI group (55.6 vs. 10%, P=0.004). A higher risk of variceal recurrence was observed in the CI group (33 vs. 57%, P=0.04).
No significant differences between the VBL and CI groups were observed in the treatment of EV in patients with advanced liver disease regarding mortality, variceal eradication, and major complications rates. However, minor complications and variceal recurrence were significantly more common in the CI group. In addition, there was a clear trend toward more bleeding episodes in patients included in the CI group.
European journal of gastroenterology & hepatology 11/2010; 23(1):60-5. · 1.66 Impact Factor
ABSTRACT: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures.
Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results.
46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic--11 biliary) and benign in 9 (8 chronic pancreatitis--1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2% and 52.2% for GP and 51.4% and 58.7% for GIP. Sensitivity and accuracy for EUS-FNA were 52.8% and 58.5%, respectively for GP and 69.4% e 73.2% for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9% and 69.6%, respectively) and GIP (83.8% and 84.8%, respectively) and improved agreement with final diagnosis for both (mostly for GIP).
Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.
Revista do Colégio Brasileiro de Cirurgiões 06/2010; 37(3):190-8.
ABSTRACT: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis.
to compare samples obtained with EUS-FNA using 3 different needle systems: GIP, NA-10J-1 and Shot-Gun.
19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination.
mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Specimens adequate for cytologic diagnosis were obtained in 13/19 (68. 4%) patients using GIP model, in 14/19 (73.7%) with NA10J-1 model, and in 17/19 (89.5%) with ShotGun, model (p=0.039). Histologic analysis was possible in 10/19 (52.6%) patients using the GIP model, in 14/19 (73.7%) with NA10J-1, and in 17/19 (89.5%) with Shot-Gun, model (p=0.005). Adequate samples for cytologic or histologic assessment in 16/19 (84.2%) patients using the GIP model, in 17/19 (89.5%) with NA10J-1, and in 18/19 (94.7%) with Shot-Gun, model (p=0.223). In two cases biopsies were negative due to very hard tumors.
the Shot-Gun needle obtained better samples for histological diagnosis than NA10J-1 needle and GIP.
Acta gastroenterologica Latinoamericana 07/2008; 38(2):105-15.
ABSTRACT: Endoscopic therapy has recently gained importance as an option for the treatment of pancreatic necrosis. We report a case of transgastric endoscopic resolution of pseudocyst infection and necrosis as a complication of endoscopic pseudocyst drainage.
The patient underwent several sessions of endoscopic removal of debris and necrotic material, intercalated with daily lavage and aspiration through a nasocystic tube.
At the present time, fourteen months after pancreatic pseudocyst secondary infection, the patient remains asymptomatic with no radiographic signs of pseudocyst recurrence. Transmural endoscopic therapy followed by continuous drainage and necrosectomy is a reasonable option for treating the pancreatic pseudocyst secondary infection.
JOP: Journal of the pancreas 01/2008; 9(4):499-503.
ABSTRACT: Endoscopic sclerotherapy (ES) and band ligation are standard treatments for esophageal varices. Unfortunately, recurrence is common and seems to be related to esophageal collateral vessels, easily identified by EUS. Eradication of these vessels might lead to a more durable therapeutic effect.
To compare ES with EUS-guided sclerotherapy of collateral vessels (EUS-ES).
Randomized controlled trial.
Endoscopy Unit, Division of Gastroenterology. Universidade Federal de São Paulo, São Paulo, Brazil.
Fifty cirrhotic patients with esophageal varices were randomized into 2 groups: ES (n = 25) and EUS-ES (n = 25). EUS-ES was targeted at collateral veins. Patients were followed-up for at least 6 months after eradication.
Efficacy in eradication, complications, and recurrence of varices.
Varices were eradicated in 48 patients who adhered to the study protocol. The mean (SD) number of sessions until eradication was 4.3 (1.5) for the ES group and 4.1 (1.2) for the EUS-ES group. In ES group, 4 patients had mild bleeding. In EUS-ES group, 4 patients had pain. The mean (SD) length of the follow-up period was 22.6 (6.9) months for the ES group and 24.9 (8.1) months for the EUS-ES group. Recurrence was seen in 4 patients after ES and in 2 after EUS-ES (P = .32). The presence of collateral vessels was associated with recurrence (P = .003).
EUS-ES is as safe and effective as ES in variceal eradication. Recurrence tends to be less frequent and occurs later. Persistence of esophageal collateral vessels after sclerotherapy is a risk factor for recurrence.
Gastrointestinal Endoscopy 04/2006; 63(3):396-402; quiz 463. · 4.88 Impact Factor
ABSTRACT: The diagnosis of chronic pancreatitis in early stages remains challenging and agreement between various methods is poor. Alcohol consumption is the most important cause of chronic pancreatitis.
The aim of this study was to evaluate the endosonographic evidence of pancreatic disease in patients with alcohol abuse.
Consecutive patients referred for endoscopic ultrasonography for various indications between May 2001 and December 2003.
Two hundred twenty-eight patients were enrolled in the study. One hundred 89 patients were studied; 39 (17.1%) were excluded because the pancreas could not be completely assessed (n=23) or because a previous diagnosis of chronic pancreatitis and/or pancreatic neoplasm was suspected (n=16).
Prospective study. The patients were divided into 2 groups: alcoholics (n=17) and non-alcoholics (n=172).
The assessment of pancreatic disease according to parenchymal and ductal changes as previously described by Catalano and Sahai (scores 1 and 2, respectively).
The male:female ratio was 7.5 and 0.9 in the alcoholic and the non-alcoholic groups, respectively (P=0.002). Mean ages were 53.0 and 47.8 years, respectively (P=0.156). Alcoholic patients had significantly (P<0.001) more endosonographic abnormalities than non-alcoholics for both scores. A ROC curve comparison between patients and controls showed that the best specificity and sensitivity combination was obtained for the number of EUS features greater than 1 and 2 for the scores 1 and 2, respectively.
Alcoholic patients had significantly more endosonographic abnormalities reflecting possible early changes of chronic pancreatitis. By using reported scores, values up to 1 or 2 can be seen in patients with no risk for pancreatitis, suggesting that chronic pancreatitis should be considered only for scores equal to or greater than 2 or 3 for scores 1 and 2, respectively.
JOP: Journal of the pancreas 11/2005; 6(6):568-74.
ABSTRACT: Magnification colonoscopy and contrast chromoscopy with indigo carmine dye solution have been used to differentiate neoplastic polyps (adenomas and adenocarcinomas) from non-neoplastic (hyperplastic, inflammatory, juvenile) in an attempt to obviate endoscopic polypectomy. On the other hand, little published information exists concerning conventional video colonoscopes and chromoscopy for polyp histology prediction. Aim - To assess usefullness of conventional video colonoscopes and contrast chromoscopy with indigo carmine solution for differential diagnosis of colon polyps.
In a routine colonoscopy series, we performed chromoscopy with conventional video colonoscopes before endoscopic excision of detected polyps. If a sulcus pattern was observed on the surface of the lesion, it was classified as neoplastic. Polyps were classified as non-neoplastic if no sulcus was detected on its surface. These observations were then compared with histology.
In the study period (18 months), we detected 133 polyps in 53 patients. We were able to compare results of histology and chromoscopy in 126 lesions. The sensitivity, specificity, diagnostic accuracy, negative predictive value, and positive predictive value were 56,4%, 79,2%, 65,1%, 52,8%, and 81,5%, respectively.
On the base of the presented data, we concluded that conventional video colonoscopes and contrast chromoscopy with indigo carmine solution is not a good technique for differential diagnosis of colon polyps.
Arquivos de Gastroenterologia 39(2):86-92.
ABSTRACT: Confirmation of malignancy within biliary strictures is endoscopically challenging. Dilation of strictures has been reported to enhance cytological diagnosis.
To compare brush cytology results before and after biliary stricture dilation.
Patients with extra-hepatic biliary stricture at endoscopic retrograde cholangiopancreatography were included in the study. Brushing was performed before and immediately after dilation using a 10 Fr dilating catheter. Cytology samples were classified as: negative for malignancy, presence of atypical cells, insufficient material, suspicious for malignancy or positive for malignancy. Final diagnosis was established by surgery, biopsy or follow-up.
Biliary brush cytology was performed in 50 patients, with an overall sensitivity of 40% and 27.5%, before and after dilation, respectively. The combination of results increased cancer detection rate to 45%. There were 5/50 (10%) minor complications and one death related to the procedure.
Brush cytology performed before biliary stricture dilation has a similar cancer detection rate to that following dilation, although the combination of results enhances sensitivity.
Arquivos de Gastroenterologia 43(1):20-3.
ABSTRACT: Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87% of patients. Recurrence occurred in one patient (4.3%) and rebleeding in another case (4.3%). Mild abdominal pain was described in 13% of patients. Overall mortality was 21.7% and rebleeding related mortality rate was 4.3%. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.
Arquivos de gastroenterologia 46(1):81-4.