César Vivian Lopes

OBJECTIVE: The term Barrett's esophagus refers to a premalignant condition that is characterized by the replacement of the esophageal squamous mucosa by a columnar-lined one. Preliminary studies have demonstrated reversal of Barrett's mucosa after endoscopic coagulation with different techniques associated with acid inhibition. However, most of these studies have shown that residual Barrett's glands are found underneath the new squamous epithelium in up to 40% of patients. The goal of our study is to verify whether complete restoration of Barrett's mucosa can be achieved by the combination of high power setting argon plasma coagulation and omeprazole. METHODS: A total of 33 patients (mean age: 55.2 yr, range: 21-84 yr; 21 men and 12 women) with histologically demonstrated Barrett's esophagus (mean length: 4.05 cm, range: 0.5-7 cm) were treated. Fourteen cases presented with low-grade dysplasia and one with high-grade dysplasia. All of the extent, or until a maximum of 4 cm, of the Barrett's mucosa was cauterized in each session using argon beam coagulation at a power setting of 65-70 W. All patients received 60 mg omeprazole during the treatment period. RESULTS: Complete restoration of squamous mucosa was obtained in all 33 cases after a mean of 1.96 sessions (range, 1-4). Endoscopic results were histologically confirmed. Nineteen (57.5%) patients experienced moderate to severe chest pain and odyno-dysphagia lasting for 3-10 days after the procedure. Five of these cases experienced high fever and a small volume of pleural effusion, and three patients developed esophageal strictures that needed to be dilated. Another patient developed pneumomediastinum and subcutaneous emphysema without evidences of perforation. After a mean follow-up of 10.6 months there was one endoscopic, as well as histological, recurrence of Barrett's mucosa in a patient with an ineffective laparoscopic fundoplication. CONCLUSIONS: High power setting argon plasma coagulation combined with intensive acid suppression is an effective treatment for the total endoscopic ablation of Barrett's esophagus, at least in the short term. Long-term follow-up of treated patients in whom gastroesophageal reflux is surgically or medically alleviated seems mandatory before drawing definitive conclusions about this therapy.

OBJECTIVE: Surgery is the traditional treatment for symptomatic pancreatic pseudocysts and abscesses, but morbidity and mortality are still too high. Minimally invasive approaches have been encouraged. The aim of this study was to evaluate the results of the endoscopic-ultrasound-guided (EUS) endoscopic transmural drainage of these pancreatic collections. MATERIAL AND METHODS: In this retrospective review of consecutive cases from a single referral centre, cystogastrostomy and cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control by the endoscopic insertion of straight or double pigtail stents. RESULTS: Fifty-one symptomatic patients (33 men; mean age 58 years) were submitted to 62 procedures from January 2003 to December 2005. EUS-guided drainage was successful in 48 (94%) patients. Only three patients needed surgery. There were two procedure-related complications managed clinically. During a mean follow-up of 39 weeks, recurrence due to migration or obstruction of the stent was 17.7%. All these cases were submitted to a new session of endoscopic drainage. There was no mortality. Complications were more frequent in patients with a recent episode of acute pancreatitis (38.5% versus 10%; p=0.083). The endoscopic approach was not more hazardous for abscesses in regard to complications rate (19% versus 16.6%; p>0.05). In abscesses, a nasocystic drain did not decrease the complications rate (27% versus 13%; p=0.619), but the placement of 2 stents did decrease this rate (18% versus 20%; p>0.05), although increased it in pseudocysts (40% versus 13%; p=0.185). CONCLUSIONS: Endoscopic transmural drainage is a minimally invasive, effective and safe approach in the management of pancreatic pseudocysts and abscesses.

CONTEXT: Pseudotumoral chronic pancreatitis can be difficult to differentiate from pancreatic carcinoma. OBJECTIVE: To evaluate the role of endoscopic ultrasound and fine needle aspiration in differentiating between inflammatory masses and malignancies in chronic pancreatitis. DESIGN: Retrospective study. SETTING: Tertiary care endoscopy unit. PATIENTS AND INTERVENTIONS: Between February 1997 and December 2006, 69 pancreatic head masses from patients with alcoholic chronic pancreatitis underwent EUS-FNA using a linear echoendoscope and 22-gauge needles. Final diagnoses were obtained from surgery or clinical follow-up. The patients were subdivided into two groups: pseudotumoral chronic pancreatitis and pancreatic cancer. RESULTS: Pseudotumoral masses and adenocarcinoma were found in 58 and 11 patients, respectively. The size of the lesions and the clinical presentation were similar in both groups, but the cancer patients were older than the patients with pseudotumoral masses (P=0.020). Fourteen of the 58 (24.1%) pseudotumoral masses were misdiagnosed as cancers, and 4 of the 11 (36.4%) cancers were erroneously diagnosed as pseudotumoral masses when evaluated by EUS alone. EUS-FNA confirmed the final diagnosis in 66 of the 69 (95.7%) cases. Cytopathology correctly classified 8 of the 11 (72.7%) malignancies and all benign cases. Three of the 11 (27.3%) cancers were misdiagnosed as pseudotumoral masses, and no pseudotumoral mass was diagnosed as a cancer. In two cases, the specimens were inadequate for cytopathological assessment. The sensitivity, specificity, positive and negative predictive values, and the diagnostic accuracy of EUS-FNA were 72.7%, 100%, 100%, 95.1% and 95.7%, respectively. CONCLUSIONS: The diagnostic accuracy of endoscopic ultrasound alone for differentiating between pseudotumoral masses and pancreatic cancer arising from chronic pancreatitis is unsatisfactory. Fine needle aspiration of these tumors significantly improves diagnostic capability.

AIM: To evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid tumors larger or smaller than 3 cm, and cystic lesions. METHODS: From January/1997 to December/2006, 611 patients with pancreatic tumors were subjected to EUS-FNA. The final diagnosis was obtained either by surgery (356 cases) or after a mean clinical follow-up of 11.8 mo in the remaining patients. RESULTS: There were 405 solid tumors, 189 cystic lesions and 17 mixed. Pancreatic specimens for cytological assessment were successfully obtained by EUS-FNA in 595 (97.4%) cases. There were 352 (57.6%) malignancies and 259 (42.4%) benign tumors. Among the malignancies, pancreatic adenocarcinomas accounted for 67% of the lesions. Overall, the sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA were, respectively, 78.4%, 99.2%, 99.3%, 77.2% and 87.2%. Specifically for solid tumors, the same parameters for neoplasms larger and smaller than 3 cm were, respectively, 78.8% vs 82.4%, 100% vs 98.4%, 100% vs 99%, 54.8% vs 74.1% and 83.1% vs 87.8%. For cystic lesions, the values were, respectively, 72.2%, 99.3%, 97.5%, 91% and 92.2%. CONCLUSION: EUS-FNA can be used to sample pancreatic tumors in most patients. Even though the negative predictive value is inadequate for large solid tumors, the results are rather good for small solid tumors, especially concerning the sensitivity, negative predictive value and diagnostic accuracy. Among all pancreatic lesions, EUS-FNA for cystic lesions can reveal the best negative predictive value and diagnostic accuracy, both higher than 90%.