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Endoscopic resection of small duodenal carcinoid tumors
ENDOSCOPIC TECHNOLOGY t77
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E n d o s c o p i c Resection of Small D u o d e n a l C a r c i n o i d Tumors H.Yoshikane~ H.Hidano~ A.Sakakibara~ S.Ohashi #, T.Suzuki @, E.Hamajima*, M.Matsui &, Y.Niwa&, HGoto &. 0Dept. of Internal Meal, Handa City Hosp., #Dept. of Internal Med. Toyohashi Municipal Hosp., @Aichi Cancer Center Hosp. *Dept. of Internal Med., Kariya General Hosp., &2nd Dept. of Int. Med., Nagoya Univ. Sch. of Med., Aichi, Japan. [Background & Aim] Duodenal carcinoid is the third most frequent tumor among gastrointestinal carcinoids in Japan (14.8%), in comparison with in Western countries (2-3%). Most cases of duodenal carcinoid have conventionally been treated by surgical resection. The aim of our study is to clarify the possibility of endoscopic resection of small duodenal carcinoids. [Patients and Methods] The study population consisted of 6 patients with a small duodenal carcinoid less than 10 mm in diameter undergoing endoscopic resection. The diagnosis of carcinoid was confirmed by preoperative bioptic histology. The depth of tumor invasion was preoperatively evaluated by endosonography. Confirming invasion limited to the submucosa, endoscopic resection was performed with the strip biopsy technique using a 2-channel endoscope. [Results] The carcinoid was detected by endosonography in all cases. Sizes ranged ultrasonographically from 1.5 mm to 7 mm Tumor invasion was confined to the submucosa in all cases. Endoscopic resection with the strip biopsy technique was performed on them. In all six patients, the specimens were resected without severe complication. Five of them were confirmed histologically to be carcinoid. In the remaining one, carcinoid was not detected in the specimen, however, the follow-up endoscopy has revealed no recurrent findings, as in the other 5 patients. [Conclusions] We conclude that small duodenal carcinoids confined to the submucosa can be resected endoscopically with the strip biopsy technique and that preoperative endosonography is useful and indispensable for thedetermination of endoscopic resectability.
ENDOSCOPIC MEASUREMENT OF PORTAL PRESSURE BY ENDOSCOPIC ESOPHAGOGASTRIC BALLOON TAMPONADE D.S. Zimmon~ Depts of Medicine and Radiology, St. Vincent's Hospital, New York, NY Endoscopic esophagogastric balloon tamponade controls variceal hemorrhage by occluding portal-systemic collateral blood flow through the diaphragmatic hiatus with opposed low compliance precision molded silicone esophageal and gastric balloons without traction. The 8cm long tamponade is introduced over an endoscope that is withdrawn into the proximal esophagus above the device to observe varix collapse during graded application of tamponade pressure measured with an anerold manometer. A 12.5ram lumen obliterates the gastrlc-esophageal pressure gradient (Zimmon, Gastrointestinal Endoscopy 1994;40:734-740). Varices collapse as collateral portal blood flow through th e hiatus ceases and indicates that tamponade balloon pressure is equal to portal pressure (PP). Comparison of tamponade pressure and PP measured by catheterization of the portal vein in two unstable cirrhotic patients with varlceal hemorrhage on sequential days showed similar pressures. In 4 cirrhotic patients with varices PP was measured by tamponade alone. PP is variable and fluctuates with sympathetic stimulation, blood volume, cardiac output and numerous other variables. Prior endoscopic measurements of the force required to compress varices or the pressure within varices at puncture are not reliable as they measure pressure at a variable point in a resistance loop between the portal vein and a central outflow site (Ohta, et. al. Hepatelegy 1994;20:1432-1436). Consequently varix size does not indicate the magnitude of PP. Varices may be small or absent in patients with high PP. Portal vein obstruction and shunts may limit PP measurement to splenic puncture or endoscopic methods. Only in alcoholic cirrhosis without pharmacotherapy is wedged hepatic vein pressure validated to measure of PP. PP measurement is crucial but often difficult (Feu, et. al Lancet 1995;346:1056-59). This method determines the appropriate tamponade pressure for control of bleeding, the efficacy of pharmacotherapy prior to tamponade removal and makes PP measurement at endoscopy routine adding an important physiologic measurement to endoscopic surveillance for varices.
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80
UNSEDATED PERORAL ENDOSCOPY WITH A NEW VIDEO ULTRATHIN (UT) ENDOSCOPE: PATIENT ACCEPTANCE, TOLERANCE AND DIAGNOSTIC ACCURACY. A Zaman, R Hapke, G Sahagun, RM Katon. Oregon Health Sciences University, Portland, Oregon. With the advent of smaller endoscopes, mainly fiberoptic, there has been growing interest in the feasibility of unsedated routine upper endoscopy. Aim: Assess patient tolerance of unsedated routine upper endoscopy using a new 6mm UT video endoscope (Olympus XGIF-N200H) and compare its optical quality to a standard endoscope (Olympus GIF100). Methods: 62 outpatients were recruited for unsedated UT endoscopy using topical spray followed by sedated endoscopy using a standard endoscope After unsedated endoscopy patients were asked to complete a questionnaire assessing tolerance (mild, moderate, severe or
QUANTITATIVE HISTOLOGICAL ANALYSIS OF COLONIC TISSUE USING DIFFUSE REFLECTANCE SPECTROSCOPY AT COLONOSCOPY G. Zonjos*, J. Van Dam*", LT. Perelman*, V. Beckman, R. Manoharan*, M,S. Feld*. G.R. Harrison Spectroscopy Laboratory, Massachusetts Institute of Technology, Cambridge, MA (*) and Bdgham and Women's Hospital, Harvard Medical School, Boston
no disconu~rt). Whenbothendoscopieswerecompletedthe endoscopistrecorded endoscopicfindingsand opticalqualityof the LIT (good,fair, or poor). Results: 19 of 62 patientsrefusedunseaatedendoscopybecauseof: anxiety 12, fear of gagging3, and unwillingnessto be a studypatient4, Toleranr 37 of 43 (86%) patients had a completeunsedatedUT exam(5 of the patientsdid not have a GIFI00 exam). 30 of 37 (81%) patients were willing to undergo future unsedated endoscopy with the UT and they tolerated UT endoscopy better than the patieuts that were unwilling (none/mild discomfort: 75% vs. 29%). Gender appeared to have no bearing on the willingness of a patie~ to have future unsedated endoscopy. However, willing patients tended to be older (50 vs. 38yrs). 6 of 43 (14%) patients failed UT endoscopy because of severe gagging (all were male, mean age of 44). Optics: Optical quality was rated good 83%, 63%, and 78% of the time in the esophagous, stomach, and duodenum respectively. Optical quality was diminished by excessive fluid and tenacious secretions. Endoscopic findings included: esophagitis 7, lower esophageal ring 3, Barrett's 5, esophageal stricture 1, hiatal hernia 20, gastric erosinns/erythema 6, gastric AVM's 1, gastric nodule/polyp 2, gastric ulcer 3, duodenal ulcer 3, duodenal erosions/erythema 7, and scalloped duodenal folds of celiac sprne 1 The LIT missed 5 of 59 lesions: 3 hiatal hernias, 1 gastric erosion, and 1 small gastric ulcer Conclusion: 69% of outpatients agreed to undergo peroral unsedated endoscopy with an UT endoscope. 86% of patients tolerated a complete unsedated examination and 81% of these were willing to undergo future unsedatedexammations Optical quality of this ultrathin video endoscope was good with 92% of lesions discovered when compared to a standard instrument.
AB44
GASTROINTESTINAL ENDOSCOPY
MA.(*)
The detection of mucosal dysplasia at endoscopy relies on random sampling for this endoscopically "invisible" malignant precursor. We have investigated the potential application of diffuse reflectance spectroscopy performed during colonoscopy to assess its ability to obtain histological information such as the presence of dysplasia. The objective of this study was to develop a technique that can provide pathological information to the endoscopist in real time. Reflectance spectra (range: 360-685 nm wavelength) were collected dudng colonoscopy from 11 adenomatous polyps and adjacent normalappearing mucosa in 11 patients. A 1.4 mm diameter fiber optic probe passed via the accessory channel of a standard videocolonoscope was used for data collection. The collected spectra were charactarized using a physical model of light propagation in tissue incorporating tissue properties such as light absorption and scattering, and a multilayered tissue structure. The model was formulated in terms of four parameters, 1) hemoglobin concentration, 2) mucosal thickness, 3) hemoglobin oxygenation, and 4) overall intensity of the reflectance spectra. Application of the model showed that it can accurately predict the clinical data. A unique set of the four parameters were obtained characterizing each tissue site. A detailed analysis of the four parameters showed that the adenomatous polyps contained a higher concentration of hemoglobin and were comprised of thicker mucosa when compared to the adjacent endoscopically normal-appearing mucosal sites tested. These observations were consistent with the histopathological findings. In addition, spectral intensity was found to be consistently lower and hemoglobin concentration was minimally higher in adenomatous polyps. Incorporation of this technique into a system using multi-excitation fluorescence spectroscopy (currently in progress) will provide a system with an enhanced ability to detect mucosal dysplasia at endoscopy.
VOLUME 45, NO. 4, 1997
79
E n d o s c o p i c Resection of Small D u o d e n a l C a r c i n o i d Tumors H.Yoshikane~ H.Hidano~ A.Sakakibara~ S.Ohashi #, T.Suzuki @, E.Hamajima*, M.Matsui &, Y.Niwa&, HGoto &. 0Dept. of Internal Meal, Handa City Hosp., #Dept. of Internal Med. Toyohashi Municipal Hosp., @Aichi Cancer Center Hosp. *Dept. of Internal Med., Kariya General Hosp., &2nd Dept. of Int. Med., Nagoya Univ. Sch. of Med., Aichi, Japan. [Background & Aim] Duodenal carcinoid is the third most frequent tumor among gastrointestinal carcinoids in Japan (14.8%), in comparison with in Western countries (2-3%). Most cases of duodenal carcinoid have conventionally been treated by surgical resection. The aim of our study is to clarify the possibility of endoscopic resection of small duodenal carcinoids. [Patients and Methods] The study population consisted of 6 patients with a small duodenal carcinoid less than 10 mm in diameter undergoing endoscopic resection. The diagnosis of carcinoid was confirmed by preoperative bioptic histology. The depth of tumor invasion was preoperatively evaluated by endosonography. Confirming invasion limited to the submucosa, endoscopic resection was performed with the strip biopsy technique using a 2-channel endoscope. [Results] The carcinoid was detected by endosonography in all cases. Sizes ranged ultrasonographically from 1.5 mm to 7 mm Tumor invasion was confined to the submucosa in all cases. Endoscopic resection with the strip biopsy technique was performed on them. In all six patients, the specimens were resected without severe complication. Five of them were confirmed histologically to be carcinoid. In the remaining one, carcinoid was not detected in the specimen, however, the follow-up endoscopy has revealed no recurrent findings, as in the other 5 patients. [Conclusions] We conclude that small duodenal carcinoids confined to the submucosa can be resected endoscopically with the strip biopsy technique and that preoperative endosonography is useful and indispensable for thedetermination of endoscopic resectability.
ENDOSCOPIC MEASUREMENT OF PORTAL PRESSURE BY ENDOSCOPIC ESOPHAGOGASTRIC BALLOON TAMPONADE D.S. Zimmon~ Depts of Medicine and Radiology, St. Vincent's Hospital, New York, NY Endoscopic esophagogastric balloon tamponade controls variceal hemorrhage by occluding portal-systemic collateral blood flow through the diaphragmatic hiatus with opposed low compliance precision molded silicone esophageal and gastric balloons without traction. The 8cm long tamponade is introduced over an endoscope that is withdrawn into the proximal esophagus above the device to observe varix collapse during graded application of tamponade pressure measured with an anerold manometer. A 12.5ram lumen obliterates the gastrlc-esophageal pressure gradient (Zimmon, Gastrointestinal Endoscopy 1994;40:734-740). Varices collapse as collateral portal blood flow through th e hiatus ceases and indicates that tamponade balloon pressure is equal to portal pressure (PP). Comparison of tamponade pressure and PP measured by catheterization of the portal vein in two unstable cirrhotic patients with varlceal hemorrhage on sequential days showed similar pressures. In 4 cirrhotic patients with varices PP was measured by tamponade alone. PP is variable and fluctuates with sympathetic stimulation, blood volume, cardiac output and numerous other variables. Prior endoscopic measurements of the force required to compress varices or the pressure within varices at puncture are not reliable as they measure pressure at a variable point in a resistance loop between the portal vein and a central outflow site (Ohta, et. al. Hepatelegy 1994;20:1432-1436). Consequently varix size does not indicate the magnitude of PP. Varices may be small or absent in patients with high PP. Portal vein obstruction and shunts may limit PP measurement to splenic puncture or endoscopic methods. Only in alcoholic cirrhosis without pharmacotherapy is wedged hepatic vein pressure validated to measure of PP. PP measurement is crucial but often difficult (Feu, et. al Lancet 1995;346:1056-59). This method determines the appropriate tamponade pressure for control of bleeding, the efficacy of pharmacotherapy prior to tamponade removal and makes PP measurement at endoscopy routine adding an important physiologic measurement to endoscopic surveillance for varices.
78
80
UNSEDATED PERORAL ENDOSCOPY WITH A NEW VIDEO ULTRATHIN (UT) ENDOSCOPE: PATIENT ACCEPTANCE, TOLERANCE AND DIAGNOSTIC ACCURACY. A Zaman, R Hapke, G Sahagun, RM Katon. Oregon Health Sciences University, Portland, Oregon. With the advent of smaller endoscopes, mainly fiberoptic, there has been growing interest in the feasibility of unsedated routine upper endoscopy. Aim: Assess patient tolerance of unsedated routine upper endoscopy using a new 6mm UT video endoscope (Olympus XGIF-N200H) and compare its optical quality to a standard endoscope (Olympus GIF100). Methods: 62 outpatients were recruited for unsedated UT endoscopy using topical spray followed by sedated endoscopy using a standard endoscope After unsedated endoscopy patients were asked to complete a questionnaire assessing tolerance (mild, moderate, severe or
QUANTITATIVE HISTOLOGICAL ANALYSIS OF COLONIC TISSUE USING DIFFUSE REFLECTANCE SPECTROSCOPY AT COLONOSCOPY G. Zonjos*, J. Van Dam*", LT. Perelman*, V. Beckman, R. Manoharan*, M,S. Feld*. G.R. Harrison Spectroscopy Laboratory, Massachusetts Institute of Technology, Cambridge, MA (*) and Bdgham and Women's Hospital, Harvard Medical School, Boston
no disconu~rt). Whenbothendoscopieswerecompletedthe endoscopistrecorded endoscopicfindingsand opticalqualityof the LIT (good,fair, or poor). Results: 19 of 62 patientsrefusedunseaatedendoscopybecauseof: anxiety 12, fear of gagging3, and unwillingnessto be a studypatient4, Toleranr 37 of 43 (86%) patients had a completeunsedatedUT exam(5 of the patientsdid not have a GIFI00 exam). 30 of 37 (81%) patients were willing to undergo future unsedated endoscopy with the UT and they tolerated UT endoscopy better than the patieuts that were unwilling (none/mild discomfort: 75% vs. 29%). Gender appeared to have no bearing on the willingness of a patie~ to have future unsedated endoscopy. However, willing patients tended to be older (50 vs. 38yrs). 6 of 43 (14%) patients failed UT endoscopy because of severe gagging (all were male, mean age of 44). Optics: Optical quality was rated good 83%, 63%, and 78% of the time in the esophagous, stomach, and duodenum respectively. Optical quality was diminished by excessive fluid and tenacious secretions. Endoscopic findings included: esophagitis 7, lower esophageal ring 3, Barrett's 5, esophageal stricture 1, hiatal hernia 20, gastric erosinns/erythema 6, gastric AVM's 1, gastric nodule/polyp 2, gastric ulcer 3, duodenal ulcer 3, duodenal erosions/erythema 7, and scalloped duodenal folds of celiac sprne 1 The LIT missed 5 of 59 lesions: 3 hiatal hernias, 1 gastric erosion, and 1 small gastric ulcer Conclusion: 69% of outpatients agreed to undergo peroral unsedated endoscopy with an UT endoscope. 86% of patients tolerated a complete unsedated examination and 81% of these were willing to undergo future unsedatedexammations Optical quality of this ultrathin video endoscope was good with 92% of lesions discovered when compared to a standard instrument.
AB44
GASTROINTESTINAL ENDOSCOPY
MA.(*)
The detection of mucosal dysplasia at endoscopy relies on random sampling for this endoscopically "invisible" malignant precursor. We have investigated the potential application of diffuse reflectance spectroscopy performed during colonoscopy to assess its ability to obtain histological information such as the presence of dysplasia. The objective of this study was to develop a technique that can provide pathological information to the endoscopist in real time. Reflectance spectra (range: 360-685 nm wavelength) were collected dudng colonoscopy from 11 adenomatous polyps and adjacent normalappearing mucosa in 11 patients. A 1.4 mm diameter fiber optic probe passed via the accessory channel of a standard videocolonoscope was used for data collection. The collected spectra were charactarized using a physical model of light propagation in tissue incorporating tissue properties such as light absorption and scattering, and a multilayered tissue structure. The model was formulated in terms of four parameters, 1) hemoglobin concentration, 2) mucosal thickness, 3) hemoglobin oxygenation, and 4) overall intensity of the reflectance spectra. Application of the model showed that it can accurately predict the clinical data. A unique set of the four parameters were obtained characterizing each tissue site. A detailed analysis of the four parameters showed that the adenomatous polyps contained a higher concentration of hemoglobin and were comprised of thicker mucosa when compared to the adjacent endoscopically normal-appearing mucosal sites tested. These observations were consistent with the histopathological findings. In addition, spectral intensity was found to be consistently lower and hemoglobin concentration was minimally higher in adenomatous polyps. Incorporation of this technique into a system using multi-excitation fluorescence spectroscopy (currently in progress) will provide a system with an enhanced ability to detect mucosal dysplasia at endoscopy.
VOLUME 45, NO. 4, 1997