内镜窄带成像技术在胃癌及癌前病变诊断中的应用

目的 探讨内镜窄带成像技术(NBI)对胃癌及癌前病变的诊断价值.方法 217例患者依次在普通内镜、NBI、0.2%靛胭脂染色及内镜放大(×80)模式下观察病变轮廓、胃小凹及微血管形态,评价各检查方法图像的清晰度,并结合病理学检查进行分析.结果 217例患者中,非萎缩性胃炎85例,萎缩性胃炎38例,轻度异型增生19例,中度异型增生9例,重度异型增生4例,早期胃癌5例,进展期胃癌20例,伴有肠化生者91例.NBI对病变轮廓的显示明显优于普通内镜和靛胭脂染色(P值均=0.000).经内镜放大后,NBI对胃微血管形态的显示亦优于普通内镜和靛胭脂染色(P值均=0.000).NBI模式下萎缩性胃炎胃小凹主要表现为Ⅲ、Ⅳ、Ⅴ1型,肠化生主要表现为Ⅲ、Ⅳ、Ⅴ1、Ⅴ2型,异型增生主要表现为Ⅴ1型及Ⅳ型,胃癌主要表现为Ⅵ型.结论 NBI电子染色结合放大技术有助于提高胃癌及异型增生的活检准确率和早期胃癌检出率.     

Narrow band imaging and serology in the assessment of premalignant gastric pathology

Abstract

Background: Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. Helicobacter pylori is also a strong risk factor for this disease.

Aims: Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the inter-observer agreement.

Methods: Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts.

Results: 116 patients were prospectively recruited. Diagnostic accuracy of NBI-Z for determining normal gastric mucosa was 0.87(95%CI 0.82–0.92), H. pylori gastritis 0.65(95%CI 0.55–0.75) and gastric atrophy 0.88(95%CI 0.81–0.94). NBI-Z was superior to serology at detecting gastric atrophy: NBI-Z gastric atrophy 0.88(95%CI 0.81-0.94) vs PGI/II ratio?p<.0001. Overall NBI-Z was superior to WLE-Z in detecting disease using two validated classifications. Inter-observer agreement was 0.63(95%CI 0.51–0.73).

Conclusions: NBI-Z accurately detects changes in the GI mucosa which currently depend on histology. NBI-Z is useful in the detection of precancerous conditions, potentially improving patient outcomes with early intervention to prevent gastric cancer.     

Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar: A single-blind observational study

AIM To assess the incremental benefit of narrow band imaging(NBI) and white light endoscopy(WLE), randomizing the initial technique for the detection of residual neoplasia at the polypectomy scar after an endoscopic piecemeal mucosal resection(EPMR).METHODS We conducted an observational study in an academic center to assess the incremental benefit of NBI and WLE randomly applied 1:1(NBI-WLE or WLE-NBI) in the follow-up of a post-EPMR scar by the same endoscopist.RESULTS A total of 112 EPMR scars were included. The median baseline polyp size was 20 mm(interquartile range: 14-30). At first review, NBI and WLE showed good sensitivity(85.0% vs 78.9%), specificity(77.1% vs 84.2%) and overall accuracy(80.0% vs 82.5%). NBI after WLE(WLE-NBI group) improved accuracy, but this difference was not statistically significant [area under the curve(AUC): 86.8% vs 81.6%, P = 0.15]. WLE after NBI(NBI-WLE group) did not improve accuracy(AUC: 81.4% vs 81.1%, P = 0.9). Overall, recurrence was found in 39/112(34.8%) lesions.CONCLUSION Although no statistically significant differences were found between the two techniques at the first postEPMR assessment, the use of NBI after WLE may improve residual neoplasia detection. Nevertheless, biopsy is still required in the first scar review.     

Narrow band imaging evaluation of duodenal villi in patients with and without celiac disease:A prospective study

BACKGROUND Duodenal biopsies are commonly obtained during esophagogastroduodenoscopy(EGD) but are very often histopathologically normal. Therefore, a more strategic method for evaluating the duodenal mucosa and avoiding unnecessary biopsies is needed.AIM To examine the clinical utility of narrow band imaging(NBI) for evaluating duodenal villous morphology.METHODS We performed a prospective cohort study of adult patients at Mayo Clinic Rochester from 2013-2014 who were referred for EGD with duodenal biopsies. A staff endoscopist scored, in real-time, the NBI-based appearance of duodenal villi into one of three categories(normal, partial villous atrophy, or complete villous atrophy), captured ≥ 2 representative duodenal NBI images, and obtained mucosal biopsies therein. Images were then scored by an advanced endoscopist and gastroenterology fellow, and biopsies(gold standard) by a pathologist, in a masked fashion using the same three-category classification. Performing endoscopist, advanced endoscopist, and fellow NBI scores were compared to histopathology to calculate performance characteristics [sensitivity, specificity,positive and negative, negative predictive value(NPV), and accuracy]. Inter-rater agreement was assessed with Cohen's kappa.RESULTS112 patients were included. The most common referring indications were dyspepsia(47%), nausea(23%), and suspected celiac disease(14%). Duodenal histopathology scores were: 84% normal, 11% partial atrophy, and 5% complete atrophy. Performing endoscopist NBI scores were 79% normal, 14% partial atrophy, and 6% complete atrophy compared to 91%, 5%, and 4% and 70%, 24%,and 6% for advanced endoscopist and fellow, respectively. NBI performed favorably for all raters, with a notably high(92%-100%) NPV. NBI score agreement was best between performing endoscopist and fellow(κ = 0.65).CONCLUSION NBI facilitates accurate, non-invasive evaluation of duodenal villi. Its high NPV renders it especially useful for foregoing biopsies of histopathologically normal duodenal mucosa.     

内镜窄带成像技术在早期胃癌及异型增生诊断中的应用

目的探讨内镜窄带成像技术（NBI）对早期胃癌及异型增生的诊断价值。方法217例普通胃镜和（或）NBI下表现异常者,依次采用普通放大、NBI结合放大、靛胭脂染色并放大观察,评价各检查方法图像的清晰度,并在NBI模式下于改变最显著部位活检行病理学检查。胃癌和重度异型增生者行内镜超声检查（EUS）,早期胃癌和重度异型增生者行内镜下治疗或手术治疗。结果在观察病变轮廓方面,NBI与染色内镜或普通内镜之间差异均有统计学意义,NBI最清晰,尤其是对于局灶性浅表性病变的观察;对于胃小凹的形态观察,NBI或染色内镜均优于普通内镜;在对胃黏膜微血管的观察中,NBI具有绝对优势。217例中发现轻度异型增生19例,中度异型增生9例,重度异型增生4例,早期胃癌5例。NBI模式下,胃小凹形态分为6种类型,异型增生主要表现为Ⅴ1型及Ⅳ型,早期胃癌主要表现为Ⅵ型。NBI放大内镜下3例早期胃癌可见新生或粗大血管,其中2例观察到螺旋形毛细血管。结论NBI技术操作简便,对胃黏膜病变轮廓显示清晰,放大后更可清晰观察到胃小凹及微血管形态,有助于提高早期胃癌及异型增生的靶向活检准确率。     

胃印戒细胞癌的细胞起源及其癌前病变的病理学

目的:研究胃印戒细胞癌的发生与胃腺增殖区的关系,探讨其细胞起源和癌前病变.方法:以42例早期胃印戒细胞癌为研究对象,观测其组织形态,采用免疫组织化学双染标记癌灶内分化标志物MUC5AC和MUC6的表达情况,检测癌灶不同区域Ki-67以及胃肠道干/祖细胞标志物musashi-1的表达差异,并与癌旁胃腺进行对比.结果:早期胃印戒细胞癌具有特征性的分层结构.该结构分为两层,浅表层为典型的印戒细胞,体积大,胞质丰富,基底层为原始的癌细胞,体积小,核/浆比大:在形态和解剖定位上,基底层癌细胞与癌旁胃腺增殖区细胞类似,免疫组织化学显示其MUC5AC、MUC6表达均为阴性,或仅微弱表达MUC5AC,而Ki-67、musashi-1表达率显著高于浅表层印戒细胞(t=31.0和22.8,P＜0.01);基底层癌细胞可向浅表层印戒细胞分化过渡,这与增殖区细胞向胃小凹上皮分化的过程相似;癌旁可见胃腺增殖区细胞异型增生,其表型与分层结构基底层癌细胞一致.结论:胃印戒细胞癌可能起源于增殖区MUC5AC-/low MUC6-的胃小凹前体细胞,同时增殖区的异型增生是此类胃癌的癌前病变     

Optical enhancement imaging versus acetic acid for detecting gastric intestinal metaplasia: A randomized,comparative trial

Background and aimsThe diagnosis of gastric intestinal metaplasia (GIM) is still challenging. Optical Enhancement technology (OE) may improve the detection of GIM. We compared detection of GIM with OE, acetic acid and the Sydney biopsy protocol in a surveillance population.MethodsConsecutive patients with atrophic gastritis or known GIM were prospectively included. The stomach was examined with high definition whitelight endoscopy, followed by OE or acetic acid with targeted biopsies (1:1 randomisation). Subsequently, five random biopsies were taken according to the updated Sydney system.ResultsA total of 154 patients were randomized. Higher proportions of patients with GIM were detected by OE and acetic acid versus random biopsy (60.5% vs 35.5%, 67.1% vs 31.5%, respectively; P < 0.0001 for both comparisons). The combined use of targeted biopsies and random biopsies provides high diagnostic yields for GIM (78.9% in OE group and 83.6% in acetic acid group). In addition, the proportion of extensive GIM was significantly increased when image enhanced endoscopy was used instead of white light endoscopy (P = 0.029, P = 0.048, respectively).ConclusionsOE and acetic acid showed comparable results diagnosing GIM in the study. Targeted biopsies plus random biopsies should be used complementary in high risk populations.     

Laparoscopic adjustable gastric banding induces prolonged satiety: a randomized blind crossover study

The sustainability of surgically induced weight loss implies that energy homeostasis is favorably altered. We investigated the hypothesis that laparoscopic adjustable gastric banding (LAGB) induces prolonged satiety and that plasma ghrelin is involved. Seventeen weight-stable subjects who had achieved LAGB-induced weight loss attended blind crossover breakfast tests, one with optimal band restriction and one with reduced restriction. Standardized meals were consumed (0900 h) after 14-h fasting. Satiety visual analog scales were completed hourly (0700-1100 h) before and after feeding. Blood glucose, plasma insulin, ghrelin, and leptin levels were measured. Seventeen body mass index-matched controls were tested. Optimal restriction was associated with significantly greater fasting and postprandial satiety levels than reduced restriction (P < 0.01). Glucose, insulin, ghrelin, and leptin levels did not alter between optimal and reduced restriction. LAGB subjects displayed higher ghrelin (+12%, P = 0.13) and lower glucose (-17%, P = 0.018), insulin (-33%, P = 0.016), and leptin (-32%, P = 0.05) 4-h area under the curve levels than controls. Optimal LAGB restriction increased fasting and postprandial satiety levels. This supports the hypothesis that LAGB provides prolonged satiety, present even during fasting, favorably influencing energy homeostasis. Plasma insulin, leptin, and ghrelin appeared unrelated to the satiety effect and displayed orexigenic compensatory changes. Identifying the mechanisms underlying LAGB-induced satiety may assist the understanding of human energy homeostasis and obesity.     

Thermal welding versus cold knife tonsillectomy: a prospective randomized study

This is a prospective randomized study conducted in a group of children who underwent two methods of tonsillectomy: thermal welding or cold knife tonsillectomy. Parameters, such as postoperative pain scores, intraoperative blood loss, operation time, and postoperative bleeding rates, were analyzed to find out which technique is better. Ninety-one children (aged between 2 years and 13 years) with recurrent tonsillitis, obstructive sleep apnea syndrome, or both were included in the study. According to the type of tonsillectomy procedure, the patients were divided into two groups: cold knife and thermal welding procedure. The two groups were compared on the basis of postoperative pain scores, intraoperative blood loss, operation time, and postoperative bleeding. Fifty-seven patients underwent thermal welding tonsillectomy and 34 had cold knife tonsillectomy. The mean pain score in thermal welding group was significantly lower (p<0.001). There was no remarkable blood loss intraoperatively in the thermal welding procedure. The operation time was not significantly different between two groups. No postoperative bleeding was encountered in the thermal welding group. Compared with the cold knife technique, thermal welding was found to be a relatively new and safe technique for tonsillectomy as it results in significantly less postoperative pain and no remarkable blood loss.     

A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices

Gastric variceal bleeding is a catastrophic event. Both cyanoacrylate injection and banding ligation have been proven to be effective in the management of bleeding gastric varices. This study was performed to compare the efficacy and complications of both the modalities. Cirrhotic patients with a history of gastric variceal bleeding were randomized to 2 groups. The group receiving endoscopic obturation (group A) comprised 31 patients and the group receiving band ligation (group B) comprised 29 patients. Butyl cyanoacrylate and pneumatic-driven ligator were applied, respectively. Treatment was repeated regularly until obliteration of gastric varices. Active bleeding occurred in 15 patients in group A and 11 patients in group B. Initial hemostatic rate (defined as no bleeding for 72 hours after treatment) was 87% in group A and 45% in group B (P = .03). The sessions required to achieve variceal obliteration and obliteration rates were similar in both the groups. However, rebleeding rates were significantly higher in group B (54%) than group A (31%) (P = .0005). Treatment-induced ulcer bleeding occurred in 2 patients (7%) in group A and 8 patients (28%) in group B (P = .03). The amount of blood transfusions required were also higher in group B than group A (4.2 +/- 1.3 vs. 2.6 +/- 0.9 units, respectively) (P < .01). Nine patients of group A and 14 patients of group B died (P = .05). In conclusion, endoscopic obturation using cyanoacrylate proved more effective and safer than band ligation in the management of bleeding gastric varices.     

Radiofrequency versus conventional diathermy Milligan-Morgan hemorrhoidectomy: a prospective, randomized study

Background  

In the past decade, several new surgical tools have revived the hope for an improved technique to treat radically hemorrhoids with less postoperative pain. Among these radiofrequency (RF), excisional surgery seems to be safe, fast, and accompanied by less postoperative pain. The aim of this study was to evaluate and compare RF (ligasure TM) to conventional diathermy Milligan-Morgan hemorrhoidectomy (MMH).     

Narrow band imaging with magnification for the diagnosis of lesions in the upper gastrointestinal tract

Endoscopy plays an important role in the diagnosis and management of gastrointestinal(GI)tract disorders.Chromoendoscopy has proven to be superior to white light endoscopy for early detection of various GI lesions.This has however been fraught with problems.The use of color stains,time taken to achieve an effect and the learning curve associated with the technique has been some of the pitfalls.Narrow band imaging(NBI)particularly in combination with magnifying endoscopy may allow the endoscopist to accomplish a fairly accurate diagnosis with good histological correlation similar to results achieved with chromoendoscopy.Such enhanced detection of pre-malignant and early neoplastic lesions in the gastrointestinal tract should allow better targeting of biopsies and could ultimately prove to be cost effective.Various studies have been done demonstrating the utility of this novel technology.This article will review the impact of NBI in the diagnosis of upper gastrointestinal tract disorders.