Faculty Bibliography

Background: Patients with Barrett's esophagus (BE) are enrolled in surveillance programs for the detection of dysplasia and/or early cancer and undergo 4 quadrant biopsies every 1-2 cm. The histopathological diagnosis of BE associated dysplasia has poor inter-observer agreement even amongst experienced GI pathologists. Published estimates for the inter-observer agreement (kappa values) in the reading of dysplasia in Barrett's esophagus have varied between 0.36-0.78. The WATS procedure uses a minimally invasive brush biopsy technique for acquiring wide area sampling of BE tissue. The analysis of the WATS sample is aided by a high speed computer scan which identifies potentially abnormal cells, cell clusters and abnormal glandular cells on a high resolution video monitor for pathologists to review. Approximately 200 "most suspicious" cells are then flagged by the computer as a starting point for analysis. However, the inter-observer agreement amongst pathologists using the WATS samples has not been performed. Aim: To assess inter-observer agreement among pathologists in the diagnosis of Barrett's esophagus and dysplasia using the WATS computer-assisted analysis technique. Methods: WATS slides with varying degrees of BE dysplasia were randomly selected and distributed to four pathologists trained in the analysis of WATS samples. Each pathologist completed a standardized CRF for each BE slide evaluated grading them as non-dysplastic, low-grade dysplasia (LGD) or highgrade dysplasia/esophageal adenocarcinoma (HGD/EAC). Using the published range of kappa values for histopathological diagnosis, we assumed a minimal acceptable level of reliability (pO) of 0.35 and an expected rho value (p1) of 0.55. A sample size of 60 slides using 3 reviewers would be sufficient to maintain a power of 80% with an alpha of 0.05. The kappa values were graded based on Landis and Koch scale (kappa values: 0.41 to 0.60 indicate moderate agreement, 0.61 to 0.80 indicate substantial agreement, and above 0.80 indicate nearly !

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions. Self expanding metal stents (SEMS) are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions; however they have known complications of stent migration, stent occlusion, tumor ingrowth, stricture formation, reflux, bleeding and perforation amongst others. A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces. There have only been a handful of published case reports describing this problem. In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS, and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus. SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esophageal SEMS. It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment. Early recognition and prompt management may be able to prevent further problems.

There has been limited research examining the risks, benefits, and use of common endoscopic procedures in the elderly. Furthermore, gastroenterology training programs do not routinely incorporate elderly concerns when dealing with common gastrointestinal issues. There exists a broad array of endoscopic procedures with varying inherent risks that must be weighed with each elderly patient in mind. This article discusses the benefits and drawbacks of the most common procedures and indications for endoscopy including upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, percutaneous endoscopic gastrostomy, and deep enteroscopy.

BACKGROUND: EUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited. OBJECTIVE: To assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination. DESIGN: Pooled retrospective analysis. SETTING: 6 tertiary referral centers. PATIENTS: All patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition. MAIN OUTCOME MEASUREMENTS: Diagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA. RESULTS: A total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm +/- 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis. LIMITATIONS: Retrospective study. CONCLUSIONS: Jumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.