- Email: [email protected]
Feasibility and Tolerance of the New 5.5 mm 4-Way Angulation Videoscope for Transnasal EGD for the Unsedated GI Cancer Screening in the Elderly People-Comparison with 5.2 mm 2-Way Angulation Videoscope
Abstracts
W1353 Endoscopic Submucosal Dissection (ESD) of Large Flat Lesions in the GI Tract-A New Autofluorescence (AF)-Guided Technique Andreas Probst, Hans Arnholdt, Helmut Messmann Endoscopic submucosal dissection (ESD) is an effective endoscopic method especially for large, flat lesions in the upper and lower GI tract. In flat lesions it can be difficult to visualize the margins and to determine the resection borders especially after previous endoscopic therapy (scarring) and during the resection after submucosal injection. Helpful tools in the visualization of such lesions are chromoendoscopy or narrow band imaging both in combination with magnification endoscopy, Autofluorescence endoscopy (AF) is a promising new technique to differentiate neoplastic from non-neoplastic tissue in vivo and might be another tool in the endoscopic management of such lesions. Aim: To evaluate the feasibility and the success of AF in the determination of the resection borders for ESD in flat lesions of the stomach and the rectum. Methods: 13 patients with large flat mucosal tumors in the upper and lower GI tract were treated endoscopically using the ESD technique. 7 patients had gastric lesions (4 early cancers, 3 large flat adenomas) and 6 patients presented with lesions in the rectum (4 large flat adenomas, 2 early cancers). The procedure was carried out in a standardized way. After white light endoscopy (WLE) AF was performed to determine the real extension of the lesion (XGIF-Q240FZ and XCF-H240FZI, prototypes, Olympus). AF was classified normal (green) in the surrounding mucosa and abnormal (violet) in the lesion. By using the AF mode marking of the resection borders with argon plasma coagulation followed. Submucosal injection was performed to lift the lesion. Circular incision with different knives (triangle-, hook- or insulated-tip-knife) and en bloc resection of the lesion followed. Results: Complete en bloc resection was technically possible in 9/13 patients (69,2%). The diameter of the resected lesions was 25 to 50 mm (mean 40 mm). In five of the seven gastric lesions (71,4%) the extension of the lesion was larger with AF compared to WLE. In all rectal lesions visualization was clearly improved with AF. All resected specimens showed lateral resection margins with normal mucosa. No recurrence occurred so far (mean follow-up 10 months). Conclusion: ESD is a proven technique in the treatment of premalignant lesions and early malignancies in the GI tract. The determination of the lateral resection margins can be difficult especially in large flat lesions. AF can be a promising tool in the visualization of flat lesions and can avoid underestimation of the true extension. AF is attractive because it is a simple procedure without using dies or magnification endoscopy.
W1355 Feasibility and Tolerance of the New 5.5 mm 4-Way Angulation Videoscope for Transnasal EGD for the Unsedated GI Cancer Screening in the Elderly People-Comparison with 5.2 mm 2-Way Angulation Videoscope Yoshihide Tatsumi, Akiko Harada, Takahiro Matsumoto, Tomoko Tani, Hiroshi Nishida The quality difference of transnasal EGD with 4-way and 2-way angulation scopes has not been elucidated. The smallest 5.5 mm 4-way angulation videoscope for transnasal EGD has been recently developed by Olympus (Tokyo, Japan), expecting both better transnasal insertion capability and physicians’ maneuver. Aim: To evaluate the feasibility and tolerance of the new 4-way angulation videoscope in the unsedated transnasal EGD. Methods: For the unsedated GI cancer screening in the elderly people, transnasal EGD with XGIF-XP240N2 (Field Sequential System, Field of View 120 , Distal End 5.0 mm, Insertion Tube 5.5 mm, Angulation Up210 Down90 Right100 Left100 , Instrument Channel 2 mm) (4 way) (n Z 90 M65 F25 average 62.3 y.o. unsedated oral EGD experience 87%) and GIF-N260 (Field Sequential System, Field of View 120 , Distal End 4.9 mm, Insertion Tube 5.2 mm, Angulation Up210 Down120 , Instrument Channel 2 mm) (2 way) (n Z 127 M83 F44 average 61.3 y.o. unsedated oral EGD experience 90%) were performed. Written informed consents were taken for all subjects regarding transnasal EGD procedure. Both scopes have the same optical system using the same CCD. Feasibility was compared with scores (1 poor - 5 excellent, 0 not available) modified from Dumortier et al (Gastrointest Endosc 1999;49:285-91), regarding duodenal second portion insertion(DI), target biopsy(TB), quality of whole upper GI observation(WO). The transnasal insertion rate(IR), epistaxis rate(ER) and examination time (ET) with(wB) or without biopsy (oB) were also compared. Tolerance was evaluated as the nasal pain rate (NP), the subjects’ preference rate (PR) of transnasal EGD for the next examination. Feasibility scores and examination time were investigated in 78 cases for 4 way and 100 cases for 2 way after subjects with post operated stomach or cascade stomach were excluded. Results: Data were expressed as 4 way versus (vs) 2 way with the values of mean SD. Mann-Whitney’s U test and chi-square test were used for statistics. Feasibility scores were DI3.1 1.3 vs 3.2 1.3 (ns), TB 3.2 0.9 vs 3.3 1.1 (ns), WO3.0 0.9 vs 3.0 1.0 (ns). DI was not available in 4 case for 4 way (5%) and 2 cases for 2 way (2%), while all TB was available with both scopes. Other data were IR 95.6% vs 89.8% (ns), ER 5.8% vs 7.0% (ns), ETwB 469 74.8 sec (11 cases) vs 606 136 sec (17 cases) (p Z 0.002), EToB 390 110 sec (67 cases) vs 371 95.1 sec (83 cases) (ns), NP18% vs 26% (ns) and PR 67% vs 66% (ns) (ns: not significant). Conclusion: For transnasal EGD in the elderly people, the new 4-way angulation videoscope shortened examination time with biopsy than 2-way scope, preserving transnasal insertion rate and tolerance.
W1354 In Vivo Automated Endoscopic Biopsy (AEB) with Serial Collection, Storage and Processing of Biopsy Specimens in Situ David S. Zimmon, Fred B. Smith, Forrest Manheimer, Sergei Askenof After patent filing, hand made prototypes were perfected on animal and human tissues. Then computed engineering specifications and molds were developed and modified after testing of trial biopsy parts and biopsy instruments. Finally production biopsy instruments were fabricated and tested in vitro. After FDA filings and approval by the New York Downtown Hospital IRB a 200 patient controlled trial was initiated comparing 9 French 12 specimen multibiopsy to single specimen forceps biopsy for specimen size, quality, speed of acquisition, diagnostic value and cost. The 9F AEB collects up to 12 specimens measuring 2 2 mm in a single endoscope pass. The biopsies are serially collected and stored within the tip of the AEB oriented like pancakes in order of acquisition. Chromoscopy or fluid sampling is performed via a sidearm through the open tube shaft. After use, the AEB tip containing the biopsies is separated from the shaft, placed in fixative and submitted to pathology without handling of the individual specimens. Biopsy tip storage maintains orientation and prevents specimen loss or fragmentation. A log identifies each specimen indication and site. In pathology the fixed 12 specimens, still within the tip, are processed into paraffin, mcrotomed, mounted on a single slide and stained for interpretation. The biopsies appear on the slide in order of endoscopic acquisition as documented by the endoscopic log. An AEB is sharply cut and smaller (2 2 mm) than forceps biopsies but minimizes crush and shear artifacts. Prior studies demonstrate the superior diagnostic value of multiple rather than larger biopsies (Gut 1985;26:227 & Gastrointest Endosc 1999;49:177). AEB reduces biopsy time and cost. The endoscopist biopsies with the right hand while the left hand controls the endoscope. AEB saves 3 minutes for each biopsy previously were required to pass the biopsy instrument, biopsy, remove the biopsy into fixative and repass for a second biopsy. Maintenance of endoscope and biopsy instrument position allows rapid target multibiopsy of lesions. Work place safety is improved by minimizing staff exposure to infectious material and fixative in endoscopy and pathology. In pathology specimen handling and preparation is minimized reducing cost. AEB solves many problems of prior endoscopy biopsy and processing of small specimens. Here we report the initial 10 patients that confirm the superiority of multibiopsy in specimen quality, speed of acquisition and diagnostic value compared to single biopsy forceps. These improvements reduce the duration, cost and risk to staff of endoscopic biopsy in both the endoscopy suite and pathology laboratory.
www.giejournal.org
W1356 Could Narrow Band Imaging (NBI) Replace Lugol Staining for the Detection of Esophageal Squamous Cell Carcinoma? Thierry Ponchon, Marie George Lapalus, Jean Christophe Saurin, Carlos Robles-Medranda, Marwan Chemaly, Beatrice Parmentier, Olivier Guillaud Background: Endoscopic detection of esophageal squamous cell carcinoma (SCC) lies on: 1-a meticulous analyzis of the esophageal mucosa using white light, then 2a Lugol staining to look for flat lesion undetected by white light. The NBI function aims to amplify the images of the neovessels network associated to the neoplastic process and thus to reveal superficial esophageal neoplastic lesion as a reddish area while the normal mucosa appears pale green. In a series of patients referred for esophageal endoscopic mucosal resection (EMR), we evaluated the capability of NBI function to detect esophageal SCC in comparison to Lugol staining. Material and Methods: 19 patients presenting with 22 superficial SCC of esophagus were referred for EMR. Prior treatment, esophagus was examined using white light, then NBI, and finally by Lugol staining. Any abnormal area was recorded and biopsied. Results: 31 superficial cancers were finally detected using NBI and confirmed by histology, i.e. 9 additional carcinomas in comparison to white light imaging. Lugol staining did not reveal any additional lesion in comparison to NBI. The abnormal surfaces detected by NBI and Lugol were not different: Lugol did not reveal any larger superficial tumor spreading than NBI. However, NBI revealed 11 other suspect lesions, which finally were not Lugol negative and were not neoplastic on biopsies. Five were interpretated as esophagitis. Finally, the sensitivity and specificity of NBI were respectively 100% and 75%. Conclusion: NBI is as sensitive as Lugol for the detection of esophageal SCC and for the assessment of lateral spreading. Easier to be used, NBI could replace Lugol which is rarely performed because considered as time-consuming. However, false-positive rates which result in unnecessary biopsies, should be better evaluated and explained. Also this study was done on very selected patients and results should be confirmed by a large multicenter study on at risk patients, prior recommending to substitute Lugol by NBI.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB343
W1353 Endoscopic Submucosal Dissection (ESD) of Large Flat Lesions in the GI Tract-A New Autofluorescence (AF)-Guided Technique Andreas Probst, Hans Arnholdt, Helmut Messmann Endoscopic submucosal dissection (ESD) is an effective endoscopic method especially for large, flat lesions in the upper and lower GI tract. In flat lesions it can be difficult to visualize the margins and to determine the resection borders especially after previous endoscopic therapy (scarring) and during the resection after submucosal injection. Helpful tools in the visualization of such lesions are chromoendoscopy or narrow band imaging both in combination with magnification endoscopy, Autofluorescence endoscopy (AF) is a promising new technique to differentiate neoplastic from non-neoplastic tissue in vivo and might be another tool in the endoscopic management of such lesions. Aim: To evaluate the feasibility and the success of AF in the determination of the resection borders for ESD in flat lesions of the stomach and the rectum. Methods: 13 patients with large flat mucosal tumors in the upper and lower GI tract were treated endoscopically using the ESD technique. 7 patients had gastric lesions (4 early cancers, 3 large flat adenomas) and 6 patients presented with lesions in the rectum (4 large flat adenomas, 2 early cancers). The procedure was carried out in a standardized way. After white light endoscopy (WLE) AF was performed to determine the real extension of the lesion (XGIF-Q240FZ and XCF-H240FZI, prototypes, Olympus). AF was classified normal (green) in the surrounding mucosa and abnormal (violet) in the lesion. By using the AF mode marking of the resection borders with argon plasma coagulation followed. Submucosal injection was performed to lift the lesion. Circular incision with different knives (triangle-, hook- or insulated-tip-knife) and en bloc resection of the lesion followed. Results: Complete en bloc resection was technically possible in 9/13 patients (69,2%). The diameter of the resected lesions was 25 to 50 mm (mean 40 mm). In five of the seven gastric lesions (71,4%) the extension of the lesion was larger with AF compared to WLE. In all rectal lesions visualization was clearly improved with AF. All resected specimens showed lateral resection margins with normal mucosa. No recurrence occurred so far (mean follow-up 10 months). Conclusion: ESD is a proven technique in the treatment of premalignant lesions and early malignancies in the GI tract. The determination of the lateral resection margins can be difficult especially in large flat lesions. AF can be a promising tool in the visualization of flat lesions and can avoid underestimation of the true extension. AF is attractive because it is a simple procedure without using dies or magnification endoscopy.
W1355 Feasibility and Tolerance of the New 5.5 mm 4-Way Angulation Videoscope for Transnasal EGD for the Unsedated GI Cancer Screening in the Elderly People-Comparison with 5.2 mm 2-Way Angulation Videoscope Yoshihide Tatsumi, Akiko Harada, Takahiro Matsumoto, Tomoko Tani, Hiroshi Nishida The quality difference of transnasal EGD with 4-way and 2-way angulation scopes has not been elucidated. The smallest 5.5 mm 4-way angulation videoscope for transnasal EGD has been recently developed by Olympus (Tokyo, Japan), expecting both better transnasal insertion capability and physicians’ maneuver. Aim: To evaluate the feasibility and tolerance of the new 4-way angulation videoscope in the unsedated transnasal EGD. Methods: For the unsedated GI cancer screening in the elderly people, transnasal EGD with XGIF-XP240N2 (Field Sequential System, Field of View 120 , Distal End 5.0 mm, Insertion Tube 5.5 mm, Angulation Up210 Down90 Right100 Left100 , Instrument Channel 2 mm) (4 way) (n Z 90 M65 F25 average 62.3 y.o. unsedated oral EGD experience 87%) and GIF-N260 (Field Sequential System, Field of View 120 , Distal End 4.9 mm, Insertion Tube 5.2 mm, Angulation Up210 Down120 , Instrument Channel 2 mm) (2 way) (n Z 127 M83 F44 average 61.3 y.o. unsedated oral EGD experience 90%) were performed. Written informed consents were taken for all subjects regarding transnasal EGD procedure. Both scopes have the same optical system using the same CCD. Feasibility was compared with scores (1 poor - 5 excellent, 0 not available) modified from Dumortier et al (Gastrointest Endosc 1999;49:285-91), regarding duodenal second portion insertion(DI), target biopsy(TB), quality of whole upper GI observation(WO). The transnasal insertion rate(IR), epistaxis rate(ER) and examination time (ET) with(wB) or without biopsy (oB) were also compared. Tolerance was evaluated as the nasal pain rate (NP), the subjects’ preference rate (PR) of transnasal EGD for the next examination. Feasibility scores and examination time were investigated in 78 cases for 4 way and 100 cases for 2 way after subjects with post operated stomach or cascade stomach were excluded. Results: Data were expressed as 4 way versus (vs) 2 way with the values of mean SD. Mann-Whitney’s U test and chi-square test were used for statistics. Feasibility scores were DI3.1 1.3 vs 3.2 1.3 (ns), TB 3.2 0.9 vs 3.3 1.1 (ns), WO3.0 0.9 vs 3.0 1.0 (ns). DI was not available in 4 case for 4 way (5%) and 2 cases for 2 way (2%), while all TB was available with both scopes. Other data were IR 95.6% vs 89.8% (ns), ER 5.8% vs 7.0% (ns), ETwB 469 74.8 sec (11 cases) vs 606 136 sec (17 cases) (p Z 0.002), EToB 390 110 sec (67 cases) vs 371 95.1 sec (83 cases) (ns), NP18% vs 26% (ns) and PR 67% vs 66% (ns) (ns: not significant). Conclusion: For transnasal EGD in the elderly people, the new 4-way angulation videoscope shortened examination time with biopsy than 2-way scope, preserving transnasal insertion rate and tolerance.
W1354 In Vivo Automated Endoscopic Biopsy (AEB) with Serial Collection, Storage and Processing of Biopsy Specimens in Situ David S. Zimmon, Fred B. Smith, Forrest Manheimer, Sergei Askenof After patent filing, hand made prototypes were perfected on animal and human tissues. Then computed engineering specifications and molds were developed and modified after testing of trial biopsy parts and biopsy instruments. Finally production biopsy instruments were fabricated and tested in vitro. After FDA filings and approval by the New York Downtown Hospital IRB a 200 patient controlled trial was initiated comparing 9 French 12 specimen multibiopsy to single specimen forceps biopsy for specimen size, quality, speed of acquisition, diagnostic value and cost. The 9F AEB collects up to 12 specimens measuring 2 2 mm in a single endoscope pass. The biopsies are serially collected and stored within the tip of the AEB oriented like pancakes in order of acquisition. Chromoscopy or fluid sampling is performed via a sidearm through the open tube shaft. After use, the AEB tip containing the biopsies is separated from the shaft, placed in fixative and submitted to pathology without handling of the individual specimens. Biopsy tip storage maintains orientation and prevents specimen loss or fragmentation. A log identifies each specimen indication and site. In pathology the fixed 12 specimens, still within the tip, are processed into paraffin, mcrotomed, mounted on a single slide and stained for interpretation. The biopsies appear on the slide in order of endoscopic acquisition as documented by the endoscopic log. An AEB is sharply cut and smaller (2 2 mm) than forceps biopsies but minimizes crush and shear artifacts. Prior studies demonstrate the superior diagnostic value of multiple rather than larger biopsies (Gut 1985;26:227 & Gastrointest Endosc 1999;49:177). AEB reduces biopsy time and cost. The endoscopist biopsies with the right hand while the left hand controls the endoscope. AEB saves 3 minutes for each biopsy previously were required to pass the biopsy instrument, biopsy, remove the biopsy into fixative and repass for a second biopsy. Maintenance of endoscope and biopsy instrument position allows rapid target multibiopsy of lesions. Work place safety is improved by minimizing staff exposure to infectious material and fixative in endoscopy and pathology. In pathology specimen handling and preparation is minimized reducing cost. AEB solves many problems of prior endoscopy biopsy and processing of small specimens. Here we report the initial 10 patients that confirm the superiority of multibiopsy in specimen quality, speed of acquisition and diagnostic value compared to single biopsy forceps. These improvements reduce the duration, cost and risk to staff of endoscopic biopsy in both the endoscopy suite and pathology laboratory.
www.giejournal.org
W1356 Could Narrow Band Imaging (NBI) Replace Lugol Staining for the Detection of Esophageal Squamous Cell Carcinoma? Thierry Ponchon, Marie George Lapalus, Jean Christophe Saurin, Carlos Robles-Medranda, Marwan Chemaly, Beatrice Parmentier, Olivier Guillaud Background: Endoscopic detection of esophageal squamous cell carcinoma (SCC) lies on: 1-a meticulous analyzis of the esophageal mucosa using white light, then 2a Lugol staining to look for flat lesion undetected by white light. The NBI function aims to amplify the images of the neovessels network associated to the neoplastic process and thus to reveal superficial esophageal neoplastic lesion as a reddish area while the normal mucosa appears pale green. In a series of patients referred for esophageal endoscopic mucosal resection (EMR), we evaluated the capability of NBI function to detect esophageal SCC in comparison to Lugol staining. Material and Methods: 19 patients presenting with 22 superficial SCC of esophagus were referred for EMR. Prior treatment, esophagus was examined using white light, then NBI, and finally by Lugol staining. Any abnormal area was recorded and biopsied. Results: 31 superficial cancers were finally detected using NBI and confirmed by histology, i.e. 9 additional carcinomas in comparison to white light imaging. Lugol staining did not reveal any additional lesion in comparison to NBI. The abnormal surfaces detected by NBI and Lugol were not different: Lugol did not reveal any larger superficial tumor spreading than NBI. However, NBI revealed 11 other suspect lesions, which finally were not Lugol negative and were not neoplastic on biopsies. Five were interpretated as esophagitis. Finally, the sensitivity and specificity of NBI were respectively 100% and 75%. Conclusion: NBI is as sensitive as Lugol for the detection of esophageal SCC and for the assessment of lateral spreading. Easier to be used, NBI could replace Lugol which is rarely performed because considered as time-consuming. However, false-positive rates which result in unnecessary biopsies, should be better evaluated and explained. Also this study was done on very selected patients and results should be confirmed by a large multicenter study on at risk patients, prior recommending to substitute Lugol by NBI.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB343