Aspects on endoscopic characterization and clinical management of Barrett's esophagus

Barrett's esophagus (BE) is considered to result from prolonged gastroesophageal reflux and is the only known precursor of esophageal adenocarcinoma. The clinical management of BE patients aims to control esophageal reflux to reduce mucosal injury and neoplastic progression, and to detect early neoplastic lesions in Barrett’s mucosa, suitable for curative endoscopic treatment. The first part of this thesis evaluates the effect of a stepwise increase in the dose of proton pump inhibitors (PPI), on esophageal acidic reflux, symptoms and histology in long segment BE patients (group 1, n=24). We also compare these outcomes in BE patients under PPI with the results of BE patients after clinically successful fundoplication (group 2, n=30). In all but one patient in group 1, it was possible to normalize acid reflux with PPI, resulting in improvements in symptom scores. However, symptomatic amelioration was only significant in the first step of PPI treatment. Patients with PPI or fundoplication had the same levels of symptom scores. Normalization of the acid reflux in both groups was associated with reductions of papillary length, thickness of the basal cell layers, dilation of intercellular spaces, and acute and chronic inflammation of the squamous epithelium. We did not find a significant change in markers of proliferation and differentiation in Barrett’s mucosa associated with normalization of acid reflux in either group. The second part of this thesis assesses 3 different endoscopic classification systems, Amsterdam, Kansas and Nottingham, developed for the characterization of Barrett’s mucosa. These classifications use magnification endoscopy with narrow band imaging (ME-NBI) for the identification of intestinal metaplasia and dysplasia in Barrett’s mucosa. We used 84 video segments from Barrett’s mucosa, that were randomly selected and blindly evaluated by 9 observers with different expertise in the field. All classifications were feasibly but showed suboptimal accuracy and low inter-observer agreement, with slightly better results for the Amsterdam classification. The last part of this thesis evaluates the role of a structured learning program for the application of the Amsterdam classification system. We used the first 70 videos from the 84 randomly selected videos from the previous study. While, during the learning process, there was a decrease in the time spent for evaluation and an increase in declared certainty of prediction, the accuracy in histological prediction did not improve. This classification system was found to be suboptimal in terms of accuracy and inter- and intra-observer agreements. This thesis shows that, in long segment BE patients, acid reflux and symptom scores correlated through several steps of the PPI treatment process, achieving the same level as after a successful fundoplication. If a single dose of PPI is associated with marked improvement of symptoms, higher doses still may be needed for complete acid suppression. Minor changes were found among morphological markers of reflux disease, both in the glandular and in the squamous epithelium, irrespective of medical or surgical treatment. Our results underscore the questionable utility of ME-NBI classification systems for clinical routine practice in BE

Clip and snare lifting technique to assist cannulation of a papilla hidden behind a mucosal fold

No abstract availabl

Reconstructing discards profiles of unreported catches

In Portugal it has been estimated that unreported catches represent one third of total catches. Herein, information on landings and total unreported catches (discards) by commercial métier were disaggregated into high taxonomic detail using published scientific studies. Fish accounted for 93.5% (115493 t) of overall unreported catches per year, followed by cephalopods (2345 t, 1.9%) and crustaceans (1754 t, 1.4%). Sharks accounted for 1.3% of total unreported catches in weight (1638 t/y). Unreported taxa consisted mostly of the commercial landed fish species: Scomber colias, Boops boops, Trachurus picturatus, T. trachurus, Merluccius merluccius, Sardina pilchardus, Liza aurata and Micromesistius poutassou, which together accounted for 70% of the unreported discarded catches. The number of unreported/discarded species was highest in artisanal fisheries, followed by trawl and purse seine. In artisanal fisheries, L. aurata, S. colias, S. pilchardus, Trachinus draco and B. boops accounted for 76.4% of the unreported discards. B. boops, S. colias and S. pilchardus were also among the most discarded purse seine species, together with Belone belone accounting for 79% of the unreported catches. In trawl fisheries, T. picturatus (16%), M. merluccius (13%), S. colias (13%) and M. poutassou (13%) accounted for 55% of the trawl discarded unreported catches. The discarded species that most contribute to overall unreported catches are those that are most frequently landed and that most contribute to overall landings in weight.SFRH/BD/104209/2014 and SFRH/ BPD/108949/2015). This work received national funds through the Foundation for Science and Technology (FCT) through project UID/Multi/04326/2013. Karim Erzini was supported by funding from the European Commission’s Horizon 2020 Research and Innovation Programme under Grant Agreement No. 634495 for the project Science, Technology, and Society Initiative to minimize Unwanted Catches in European Fisheries (MINOUW)info:eu-repo/semantics/publishedVersio

Low risk of local recurrence after a successful en bloc Endoscopic Submucosal Dissection for non-invasive colorectal lesions with positive horizontal resection margins(R-ESD study)

BACKGROUND : During endoscopic submucosal dissection (ESD), the normal mucosa is cut under constant optical control. We studied whether a positive horizontal resection margin after a complete en bloc ESD predicts local recurrence. METHODS:  In this European multicenter cohort study, patients with a complete en bloc colorectal ESD were selected from prospective registries. Cases were defined by a horizontal resection margin that was positive or indeterminate for dysplasia (HM1), whereas controls had a free resection margin (HM0). Low risk lesions with submucosal invasion (T1) and margins free of carcinoma were analyzed separately. The main outcome was local recurrence. RESULTS:  From 928 consecutive ESDs (2011-2020), 354 patients (40 % female; mean age 67 years, median follow-up 23.6 months), with 308 noninvasive lesions and 46 T1 lesions, were included. The recurrence rate for noninvasive lesions was 1/212 (0.5 %; 95 %CI 0.02 %-2.6 %) for HM0 vs. 2/96 (2.1 %; 95 %CI 0.57 %-7.3 %) for HM1. The recurrence rate for T1 lesions was 1/38 (2.6 %; 95 %CI 0.14 %-13.5 %) for HM0 vs. 2/8 (25 %; 95 %CI 7.2 %-59.1 %) for HM1. CONCLUSION:  A positive horizontal resection margin after an en bloc ESD for noninvasive lesions is associated with a marginal nonsignificant increase in the local recurrence rate, equal to an ESD with clear horizontal margins. This could not be confirmed for T1 lesions

Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers

Background and study aims Overcoming logistical obstacles for the implementation of colorectal endoscopic submucosal dissection (ESD) requires accurate prediction of procedure times. We aimed to evaluate existing and new prediction models for ESD duration. Patients and methods Records of all consecutive patients who underwent single, non-hybrid colorectal ESDs before 2020 at three Dutch centers were reviewed. The performance of an Eastern prediction model [GIE 2021;94(1):133-144] was assessed in the Dutch cohort. A prediction model for procedure duration was built using multivariable linear regression. The model's performance was validated using internal validation by bootstrap resampling, internal-external cross-validation and external validation in an independent Swedish ESD cohort. Results A total of 435 colorectal ESDs were analyzed (92% en bloc resections, mean duration 139 minutes, mean tumor size 39 mm). The performance of current unstandardized time scheduling practice was suboptimal (explained variance: R 2 =27%). We successfully validated the Eastern prediction model for colorectal ESD duration <60 minutes (c-statistic 0.70, 95% CI 0.62-0.77), but this model was limited due to dichotomization of the outcome and a relatively low frequency (14%) of ESDs completed <60 minutes in the Dutch centers. The model was more useful with a dichotomization cut-off of 120 minutes (c-statistic: 0.75; 88% and 17% of "easy" and "very difficult" ESDs completed <120 minutes, respectively). To predict ESD duration as continuous outcome, we developed and validated the six-variable cESD-TIME formula ( https://cesdtimeformula.shinyapps.io/calculator/ ; optimism-corrected R 2 =61%; R 2 =66% after recalibration of the slope). Conclusions We provided two useful tools for predicting colorectal ESD duration at Western centers. Further improvements and validations are encouraged with potential local adaptation to optimize time planning

Correction: Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers

[This corrects the article DOI: 10.1055/a-2122-0419.]

Agreement on endoscopic ultrasonography-guided tissue specimens: Comparing a 20-G fine-needle biopsy to a 25-G fine-needle aspiration needle among academic and non-academic pathologists

Background and Aim: A recently carried out randomized controlled trial showed the benefit of a novel 20-G fine-needle biopsy (FNB) over a 25-G fine-needle aspiration (FNA) needle. The current study evaluated the reproducibility of these findings among expert academic and non-academic pathologists. Methods: This study was a side-study of the ASPRO (ASpiration versus PROcore) study. Five centers retrieved 74 (59%) consecutive FNB and 51 (41%) FNA samples from the ASPRO study according to randomization; 64 (51%) pancreatic and 61 (49%) lymph node specimens. Samples were re-reviewed by five expert academic and five non-academic pathologists and rated in terms of sample quality and diagnosis. Ratings were compared between needles, expert academic and

Endoscopic Submucosal Tunnel Dissection for Esophageal Granular Cell Tumor Resection

Endoscopic submucosal tunnel dissection (ESTD) was recently described for the resection of upper gastrointestinal submucosal tumors, namely leiomyomas, GISTs and aberrant pancreas. Granular cell tumors (GCT) are usually benign, but should be removed when symptomatic, significantly increase in size or have atypical histological or ultrasonographic features.We aim to describe the role of ESTD for the resection of an esophageal GCT. A 51 year-old patient was referred to us due to the presence of an esophageal submucosal lesion with increased size in the follow-up. Deep biopsy specimens were positive for granular cell tumor. Suboptimal submucosal lifting precluded conventional endoscopic submucosal dissection (ESD). In this context an ESTD was performed. First, a submucosal tunnel was created starting 5 cm above the tumor. Afterwards, the GCT was carefully dissected from the overlying submucosa and muscularis propria using TT knife and IT knife2. The ESTD procedure was possible and en bloc resection achieved, being the 25 mm long lesion retrieved. The mucosal orifices were closed using conventional clips. The patient started oral diet 1 day after ESTD and was discharged at day 4 without any complications. In this first report of ESTD for esophageal GCT resection, this technique shown to be feasible, reliable and safe, enabling complete resection, even in this case with poor submucosal lifting. Keywords: Endoscopic submucosal tunnel dissection, Granular cell tumor, Submucosal tumor, Esophagus, Vide