Endoscopic resection for treatment of mucosal Barrett's cancer: time to swing the pendulum.
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Adenocarcinoma↗
Biomedical subjects
Jacques J G H M Bergman
Publications and source records attributed to Jacques J G H M Bergman.
Comparison of kinome profiles of Barrett's esophagus with normal squamous esophagus and normal gastric cardia.
The precursor metaplastic mucosal lesion that predisposes for esophageal adenocarcinoma is Barrett's esophagus. Because the signal transduction events that occur in Barrett's esophagus are poorly understood, this study aimed at generating a comprehensive description of cellular kinase activity in Barrett's esophagus, normal squamous esophagus, and gastric cardia to gain more insight into the pathogenesis of Barrett's esophagus. Peptide arrays, exhibiting 1,176 specific consensus sequences for protein kinases, were used to produce a global analysis of cellular kinase activity in biopsies of Barrett's esophagus, and results were compared with the neighboring cardia and squamous epithelia. Several differences in kinase activity using immunoblot analysis and enzyme activity assays were validated in biopsies of 27 Barrett's esophagus patients. Three unique kinome profiles are described and compared. We identified cascades of activated kinases showing that mitogen-activated protein kinase and epidermal growth factor receptor activity are both significantly altered in Barrett's esophagus compared with squamous and gastric cardia epithelia. Another novel finding is that the glycolysis pathway is significantly up-regulated in Barrett's esophagus, which is illustrated by an up-regulated pyruvate kinase activity. Here, the unique kinome profile of Barrett's esophagus is made available as a comprehensive database. Several signaling pathways are revealed as specifically expressed in Barrett's esophagus when compared with the adjacent normal epithelia. These unique findings provide novel insight in the pathogenesis of Barrett's esophagus that will ultimately help to resolve the increasing problem of Barrett's esophagus and prevention of esophageal adenocarcinoma.
Adult↗
The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.
BACKGROUND & AIMS: Barrett's esophagus (BE) is a premalignant condition for esophageal adenocarcinoma, its diagnosis relying initially on recognition of a columnar-lined distal esophagus. We aimed to develop and validate explicit, consensus-driven criteria for the endoscopic diagnosis and grading of BE. METHODS: An international working group agreed on criteria and developed materials for their formal evaluation using video-endoscopic recordings gathered in a standardized manner in 29 patients. The criteria included assessment of the circumferential (C) and maximum (M) extent of the endoscopically visualized BE segment as well as endoscopic landmarks. The recordings were scored according to these criteria by a separate international panel of 29 endoscopists. RESULTS: The Prague C & M Criteria give explicit guidance on the endoscopic recognition of BE and grading of its extent. The overall reliability coefficients (RC) for the assessment of the C & M extent of the endoscopic BE segment above the gastroesophageal junction were 0.95 and 0.94, respectively. The rates of exact agreement (for C & M values) for pairwise comparisons of individual patient values were 53% and 38%, respectively, whereas the values for agreement within a 2-cm interval were 97% and 95%, respectively. The overall RC for endoscopic recognition of BE >/=1 cm was 0.72, whereas for BE <1 cm, it was 0.22. The RCs for recognizing the location of the gastroesophageal junction and the diaphragmatic hiatus were 0.88 and 0.85, respectively. CONCLUSIONS: The Prague C & M Criteria have high overall validity for the endoscopic assessment of visualized BE lengths.
Barrett Esophagus↗
The endoscopic diagnosis and staging of oesophageal adenocarcinoma.
The endoscopic evaluation of patients with oesophageal adenocarcinoma does not only serve the purpose of diagnosing the lesion and obtaining biopsies for histological evaluation: a systematic description of advanced lesions is also required to guide further therapeutic decisions. New endoscopic imaging modalities hold the promise of better endoscopic detection of early cancer and its precursor lesions in Barrett's oesophagus. Video-autofluorescence and narrow band imaging are the most promising techniques in this respect. The former may be used as a 'red flag' technique, identifying lesions that remain occult with white light endoscopy; the latter may be used as a targeted imaging technique, allowing for detailed inspection of the mucosal and vascular patterns that may help to distinguish early neoplasia from non-dysplastic tissue. Currently, prototypes are under investigation that combine high-resolution endoscopy, narrow band imaging and video-autofluorescence in one endoscopy system. Endoscopic ultrasonography (EUS) is superior to any other imaging modality in the assessment of local tumour infiltration of oesophageal adenocarcinoma and locoregional lymph nodes status. EUS allows for the identification of patients with advanced disease who are unlikely to benefit from attempts at curative surgery and in whom a conservative palliative treatment is indicated. EUS may also play a role in the selection of patients for local endoscopic treatment of early oesophageal cancer. EUS guided fine needle aspiration (EUS-FNA) of locoregional lymph nodes is safe with a high sensitivity and an impeccable specificity for assessment of malignant involvement. The indications for EUS-FNA of lymph nodes, however, depend on local treatment protocols: caeliac nodes (M1a) and lymph nodes located at or above the subcarinal area are the most widely used indications. In addition, it may be important if the choice for specific treatment protocols (e.g. neoadjuvant chemoradiotherapy) depends on lymph node status.
Adenocarcinoma↗
Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging.
BACKGROUND: The detection of the mucosal morphology (ie, mucosal and vascular patterns) in Barrett's esophagus (BE) by magnifying (chromo)endoscopy may improve the distinction of high-grade intraepithelial neoplasia (HGIN) from nondysplastic specialized intestinal metaplasia (SIM). Narrow band imaging (NBI) is a new technique that uses optical filters to enhance the mucosal contrast without the need for chromoendoscopy. OBJECTIVE: To use NBI for the characterization and the classification of the mucosal morphology in nondysplastic BE and in BE with HGIN. DESIGN: Descriptive study. SETTING: Single-center study in a tertiary referral center for the diagnosis and treatment of patients with BE. PATIENTS: We used NBI with magnifying endoscopy to image and biopsy randomly selected areas in 63 patients with BE. A systematic image and a biopsy specimen evaluation process was followed, including unblinded assessment of an exploratory set of images and biopsy specimens, and blinded evaluation of learning and validation sets. MAIN OUTCOME MEASUREMENTS: The relationship between the mucosal morphology and the presence of SIM and HGIN. RESULTS: SIM was characterized by either villous/gyrus-forming patterns (80%), which were mostly regular and had regular vascular patterns, or a flat mucosa with regular normal-appearing long branching vessels (20%). HGIN was characterized by 3 abnormalities: irregular/disrupted mucosal patterns, irregular vascular patterns, and abnormal blood vessels. All areas with HGIN had at least 1 abnormality, and 85% had 2 or more abnormalities. The frequency of abnormalities showed a significant rise with increasing grades of dysplasia. The magnified NBI images had a sensitivity of 94%, a specificity of 76%, a positive predictive value of 64%, and a negative predictive value of 98% for HGIN. LIMITATIONS: No data on observer agreement. CONCLUSIONS: NBI with magnification reveals the mucosal morphology characteristics of nondysplastic BE and HGIN, without the need for staining and has a relatively high diagnostic value for HGIN when used for targeted detailed examination of areas of interest.
Aged↗
Endoscopic video-autofluorescence imaging followed by narrow band imaging for detecting early neoplasia in Barrett's esophagus.
BACKGROUND: Video-autofluorescence imaging (AFI) and narrow band imaging (NBI) are new endoscopic techniques that may improve the detection of high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus (BE). AFI improves the detection of lesions but may give false-positive findings. NBI allows for detailed inspection of the mucosal and (micro)vascular patterns, which are related to HGIN. OBJECTIVE: A proof-of-principle study to combine AFI and NBI to improve the detection of HGIN and to reduce false-positive findings. DESIGN: Cross-sectional study of consecutive eligible patients. SETTING: Single-center. PATIENTS: Twenty patients with BE with suspected or endoscopically treated HGIN were investigated with 2 prototype imaging systems: AFI (inspection with high-resolution videoendoscopy and autofluorescence imaging for detection of lesions) and NBI (for detailed inspection of mucosal and vascular patterns of identified lesions). Lesions were sampled for histopathologic evaluation. MAIN OUTCOME MEASUREMENTS: The positive predictive value of AFI alone and of AFI-NBI for detecting HGIN and the reduction of false-positive findings because of the use of NBI. RESULTS: All of the 28 lesions with HGIN were identified with AFI. Seventeen were identified with white light (61%). Forty-seven suspicious lesions were detected with AFI: 28 contained HGIN (60%) and 19 were false positive (40%). With NBI, 25 of the true-positive lesions had definitely suspicious patterns, and 3 had dubiously suspicious patterns. Of the 19 false positives, 14 were not suspicious on NBI. The false-positive rate, therefore, was reduced from 40% to 10%. Low-grade dysplasia was found in 4 of the remaining 5 false positives. All of the 14 patients with HGIN were identified by AFI-NBI (sensitivity 100%). LIMITATIONS: Uncontrolled study in high-risk patients. CONCLUSIONS: This proof-of-principle study confirms that AFI can be used as a red-flag technique to detect suspicious lesions. With NBI, detailed inspection of the surface patterns can be performed. This combination may increase the accuracy of detecting HGIN in BE.
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New developments in the endoscopic detection and treatment of early neoplasia in Barrett's oesophagus.
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Barrett Esophagus↗
Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study.
OBJECTIVES: Endoscopic therapy for early neoplasia in Barrett's esophagus (BE) is evolving rapidly. Aim of this study was to prospectively evaluate safety and efficacy of stepwise radical endoscopic resection (ER) of BE containing early neoplasia. METHODS: Patients with early neoplasia (i.e., high-grade intraepithelial neoplasia or early cancer) in BE < or = 5 cm, without signs of submucosal infiltration or lymph node/distant metastases, were included. Patients underwent resection sessions (cap technique after submucosal lifting) with intervals of 6 wk. RESULTS: Between January 2003 and December 2004, 39 consecutive patients were included. Therapy was discontinued in two patients due to unrelated comorbidity. Complete eradication of early neoplasia was achieved in all 37 treated patients in a median number of three sessions. Complete removal of all Barrett's mucosa was achieved in 33 (89%) patients: 4 patients (all had undergone APC [argon plasma coagulation]) were found to have small isles of Barrett's mucosa underneath neosquamous mucosa. Complications occurred in two out of 88 (2%) ER procedures: one asymptomatic perforation, one delayed bleeding. Symptomatic stenosis occurred in 10 of 39 (26%) patients and was effectively treated by endoscopic bougienage. During a median follow-up of 11 months, no patients died and none had recurrence of neoplasia or Barrett's mucosa. CONCLUSIONS: Stepwise radical ER is effective for selected patients with early neoplasia in BE; provides optimal histopathological diagnosis; and may reduce recurrence rate, since all mucosa at risk is effectively removed. Use of APC should be limited to prevent buried Barrett's mucosa. Methods for prevention of stenosis should be developed.
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Endoscopic treatment of high-grade intraepithelial neoplasia and early cancer in Barrett oesophagus.
In the last 5 years, endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) and early cancer (EC) in Barrett oesophagus has emerged as an effective and safe alternative to surgery. Adequate work-up of patients includes histopathological review of the initial biopsies, a high-resolution endoscopy with four-quadrant random biopsies every 1cm of Barrett mucosa and staging with endoscopic ultrasonography. Endoscopic resection (ER) forms the mainstay of the endoscopic treatment since it provides large tissue specimens for optimal histopathological evaluation. The ER-cap technique with submucosal injection and the 'suck-band-and cut' method are the resection methods most widely used in Barrett oesophagus patients. ER monotherapy for HGIN or EC in Barrett oesophagus is associated with recurrent lesions in up to 30% of treated patients. ER may be combined with ablative techniques such as photodynamic therapy (PDT) to treat all of the mucosa at risk for neoplastic progression. Unlike ER, PDT lacks histopathological correlation and residual Barrett mucosa may remain after treatment or may be hidden underneath the neosquamous epithelium. Management of Barrett oesophagus patients with HGIN or EC should be performed in centres with multi-disciplinary experience in this field and future studies should focus on development of ER techniques that allow radical resection of the whole Barrett segment.
Barrett Esophagus↗
Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett's esophagus.
BACKGROUND: The aim of this study was to investigate the feasibility of detecting high-grade dysplasia (HGD) and early cancer (EC) in Barrett's esophagus (BE) with a prototype video autofluorescence endoscope. METHODS: Sixty patients with BE were evaluated with a prototype, high-resolution videoendoscope that has separate charge-coupled devices for white light endoscopy (WLE) and autofluorescence imaging (AFI). Nondysplastic BE appears green on AFI, whereas potentially neoplastic areas appear blue/violet. The BE was first screened with WLE for visible abnormalities and then was examined by AFI to detect additional lesions. Lesions that raised a suspicion of neoplasia and control areas that were normal on AFI were sampled for histopathologic assessment. Finally, random 4-quadrant biopsy specimens were obtained at 2-cm intervals. RESULTS: A diagnosis of HGD/EC was made in 22 patients; one patient had no visible abnormality, and 21 had endoscopically detectable areas with HGD/EC. In 6 of the latter 21 patients, the HGD/EC was detected with AFI alone; in another patient, HGD/EC was detected with AFI and random biopsies. In 14 patients, HGD/EC was detected with both WLE and AFI; in 3 of these 14 patients, additional lesions containing HGD/EC were detected by AFI alone. CONCLUSIONS: The results of this study suggest that video AFI may improve the detection of HGD/EC in patients with BE.
Aged↗
A randomized crossover study comparing light-induced fluorescence endoscopy with standard videoendoscopy for the detection of early neoplasia in Barrett's esophagus.
BACKGROUND: Light-induced fluorescence endoscopy (LIFE) may improve the detection of high-grade dysplasia (HGD) and early stage cancer (EC) in Barrett's esophagus (BE). The aim of this study was to compare LIFE with standard endoscopy (SE) in a randomized crossover study. METHODS: Fifty patients with BE underwent SE and LIFE in a randomized sequence (4 to 6-week interval between procedures). The two procedures were performed by two different endoscopists who were blinded to the findings of the other examination. Targeted biopsy specimens were taken from detected lesions, followed by random biopsy specimens with a 2-cm interval, 4-quadrant protocol. Biopsy specimens were routinely evaluated and subsequently reviewed by a single, blinded expert GI pathologist. RESULTS: Targeted biopsy specimens had a sensitivity for the diagnosis of HGD/EC of 62% (8/13) for both techniques. The overall sensitivity (all biopsy specimens) was 85% for SE and 69% for LIFE (p = 0.69). All targeted biopsy specimens had a positive predictive value (PPV) for HGD/EC of 41% for SE and 28% for LIFE (p = 0.40); autofluorescence-targeted biopsy specimens had a PPV of 13%. False-positive lesions had a significantly higher rate of acute inflammation than random biopsy specimens. CONCLUSIONS: In this study, LIFE did not improve the detection of HGD or EC in patients with BE compared with SE.
Barrett Esophagus↗
Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus.
BACKGROUND: The aim of this study was to prospectively evaluate endoscopic resection (ER) combined with photodynamic therapy (PDT) for the treatment of selected patients with early neoplasia in Barrett's esophagus. METHODS: Patients with Barrett's esophagus and neoplastic lesions <2 cm in diameter and no sign of submucosal infiltration, positive lymph nodes, or distant metastasis underwent diagnostic ER (cap technique). Patients with a T1sm tumor in the resection specimen were referred for surgery; those with a T1m or a less invasive tumor underwent additional endoscopic therapy (ER, PDT, and/or argon plasma coagulation [APC]), or they were followed. PDT was performed with 5-aminolevulinic acid and a light dose of 100 J/cm 2 at lambda = 632 nm. RESULTS: Thirty-three patients underwent diagnostic ER. Endoscopic treatment was not performed in 5 patients, who underwent surgery (4 T1sm; 1, patient preference). Five patients were immediately entered into a follow-up protocol, and 23 received additional endoscopic treatment (13 additional ER, 19 PDT, 3 APC). Endoscopic treatment was successful in 26/28 patients; no severe complication was observed. During follow-up (median 19 months, range 13-24 months), 5/26 patients had a recurrence of high-grade dysplasia: all were successfully re-treated with ER. At the end of follow-up, 26/33 originally enrolled patients (79%) and 26/28 endoscopically treated patients (93%) were in local remission. CONCLUSIONS: Endoscopic therapy is safe and effective for selected patients with early stage neoplasia in Barrett's esophagus.
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A comparative analysis by SAGE of gene expression profiles of Barrett's esophagus, normal squamous esophagus, and gastric cardia.
BACKGROUND & AIMS: The metaplastic process in which the normal squamous epithelium of the distal esophagus is replaced by columnar-lined epithelium, known as Barrett's esophagus (BE), is poorly understood. The aim of this study was to define, analyze, and compare transcription profiles of BE, normal cardia epithelium, and squamous epithelium to gain more insight into the process of metaplasia and to identify uniquely expressed genes in these epithelia. METHODS: Serial analysis of gene expression was applied for obtaining transcription libraries of biopsy specimens taken from a BE-affected patient with intestinal type of metaplasia and from normal squamous and gastric cardia epithelia. Validation of results by reverse-transcription polymerase chain reaction and immunoblotting was performed using tissues of 20 patients with BE. RESULTS: More than 120,000 tags were sequenced. Between BE and squamous 776, and between BE and gastric cardia 534 tags were significantly differentially expressed (P < .05, pairwise comparison). In contrast, squamous compared with gastric cardia epithelia showed significant differential expression of 1316 tags. The most up-regulated genes in BE compared with squamous epithelium were trefoil factors, annexin A10, and galectin-4. Each of the epithelia showed a unique cytokeratin expression profile. CONCLUSIONS: This study provides a comparison of the transcriptomes of BE, squamous epithelium, and gastric cardia epithelium. BE proves to be an incompletely differentiated type of epithelium that shows similarities to both normal squamous and gastric cardia epithelia. In addition, several uniquely expressed genes are identified. These results are a major advancement in understanding the process of metaplasia that leads to BE.
Adult↗
Diagnosis and therapy of early neoplasia in Barrett's esophagus.
PURPOSE OF THIS REVIEW: In the last 2 years, several studies have been published that will change the management of patients with Barrett's esophagus. In this review, we will discuss the most relevant studies as well as future prospects in this field. RECENT FINDINGS: Long-term follow-up studies have shown that to be cost effective, endoscopic surveillance of Barrett's esophagus patients requires a better risk stratification. A decision analysis study suggested that screening for Barrett's esophagus and restricting subsequent surveillance only to patients with dysplasia, might be the preferred strategy. New endoscopic imaging techniques such as high-resolution endoscopy, narrow band imaging, and autofluorescence endoscopy have shown promising results for detection of early mucosal lesions. Endoscopic resection techniques have emerged as a safe and effective alternative for the endoscopic treatment of patients with high-grade intraepithelial neoplasia or early cancer. Ablative techniques such as photodynamic therapy appear to be a valuable adjunct to these endoscopic resection techniques. Recent studies, however, suggest that circumferential stepwise resection of the whole Barrett's mucosa may become the preferred endoscopic treatment in these patients. SUMMARY: Risk stratification, advanced endoscopic imaging techniques, and further development of endoscopic resection techniques will improve the management of patients with Barrett's esophagus in the future.
Barrett Esophagus↗
Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features.
BACKGROUND: Endoscopic techniques are being developed for the local treatment of early stage esophageal cancer. However, such therapy is not appropriate for patients with lymph node metastasis. The aim of this study was to analyze the histopathologic features of high-grade dysplasia and early stage adenocarcinoma and to relate these to lymph node involvement. METHODS: Pathology reports were reviewed for all 367 patients who underwent subtotal esophagectomy for high-grade dysplasia or adenocarcinoma of the esophagus or the gastroesophageal junction between January 1993 and December 2001. Patients with histopathologically confirmed high-grade dysplasia or T1 carcinoma were included (n = 77). Pre-operative EUS results were assessed. All lesions were histopathologically subdivided in 6 different stages (mucosal 1-3 and submucosal 1-3). RESULTS: EUS staged 61 patients as N0. EUS correctly predicted the absence of positive lymph nodes in 57 (93%) of these patients. Histopathologically, m1, m2, m3, and sm1 cancers never had lymph node metastases, whereas 3 of 13 sm2 tumors (23%) and 9 of 13 sm3 tumors (69%) had lymph node involvement. Lymphangio invasion was present exclusively in sm2 and sm3 cancers. Factors that predicted the presence of lymph node metastasis were the following: tumor diameter greater than 3 cm, infiltration of malignancy beyond sm1, poor differentiation grade, and lymphangio invasion, although only infiltration beyond sm1 remained significant in the definitive multivariate analysis. CONCLUSIONS: EUS and the histopathologic features of high-grade dysplasia and early stage adenocarcinoma of the esophagus or the gastroesophageal junction can predict the presence of lymph node involvement. These data can be used to identify patients for whom local endoscopic treatment may be appropriate.
Adenocarcinoma↗
Gene therapy for esophageal carcinoma: the use of an explant model to test adenoviral vectors ex vivo.
Adenoviral gene therapy might be a promising therapeutic strategy for esophageal carcinoma. However, adenoviral transduction efficacy in vivo is still limited. This efficacy can be improved by the insertion of an Arg-Gly-Asp (RGD) peptide in the HI-loop of the viral fiber knob. Indeed in established esophageal cell lines, we observed an up to six-fold improved transduction using the RGD-targeted adenovirus. Established cell lines, however, are easily transformed and do not represent the more complex in vivo histology and anatomy. Therefore, we set up an esophageal explant model using esophageal biopsies from patients. Viability is a limiting factor for this system. Cultured squamous epithelium, intestinal metaplasia and squamous cell carcinoma had a sufficient viability to study adenoviral transduction. Viability of the cultured adenocarcinoma biopsies was poor. Adenoviral transduction in the explant model was poor and was localized in particular cells. The transduction of the nontargeted and RGD-targeted adenovirus was similar in localization and efficacy. In conclusion, we established an esophageal explant system to test the transduction of adenoviral vectors ex vivo. The transduction was limited and localized in specific cells. RGD-targeted adenovirus did not show an improved transduction in this system.
Adenoviridae↗
A prospective randomized trial of Tannenbaum-type Teflon-coated stents versus polyethylene stents for distal malignant biliary obstruction.
OBJECTIVE: Stent clogging is a major limitation in the palliative treatment of malignant biliary obstruction. Preliminary studies suggested improved duration of patency of a Tannenbaum design stent with a stainless steel mesh and an inner Teflon coating (TTC). We compared the patency of a TTC stent with a conventional polyethylene (PE) stent in a prospective randomized trial. METHODS: Between February 1998 and September 1998 we included 60 patients with distal malignant bile duct obstruction. Diagnosis included carcinoma of the pancreas (n = 57) and ampullary cancer (n = 3). There were 29 men and 31 women with a median age of 77 years. Stent diameter (10 Fr) and length (11 cm) were similar but both stent design and material were different: a Tannenbaum design stent with a stainless steel mesh and an inner Teflon coating, and an Amsterdam-type PE stent. RESULTS: Sixty patients were evaluated; 30 in the TTC group and 30 in the PE group. Early complications occurred in two patients in each group. Stent dysfunction occurred in 18 of TTC stents and 12 of PE stents. Median stent patency was 102 days for TTC and 142 days for PE stents (P = 0.41). Median survival did not differ significantly for both treatment groups (TTC, 121 days; PE, 105 days). Stent migration, in all cases proximal into the common bile duct, occurred in four patients in the TTC group versus zero in the PE group (P = 0.038). CONCLUSIONS: This study did not confirm improved patency of Tannenbaum-type Teflon-coated stents. Proximal migration prompts for additional design modifications.
Adult↗
Conscious sedation for EUS of the esophagus and stomach: a double-blind, randomized, controlled trial comparing midazolam with placebo.
BACKGROUND: Patients undergoing EUS usually receive intravenously administered sedative medication. A double-blind, prospective, randomized trial was conducted to compare midazolam with a placebo for EUS of the esophagus and stomach and to assess patient tolerance and endoscopic feasibility. METHODS: A total of 111 patients were randomized to receive midazolam or a placebo. Patients used a visual analogue scale to score pre-EUS anxiety and tolerance for the procedure. Endoscopists used a visual analogue scale to score ease of echoendoscope introduction and overall patient cooperation. Subsequent to EUS, patients were asked if they were willing to undergo the procedure under the same conditions. RESULTS: The patients' visual analogue scale scores indicated that tolerance for the introduction of the echoendoscope and the procedure overall were both significantly better in the midazolam group. Overall patient tolerance was predicted by sedation (p < 0.001) and pre-EUS anxiety (p = 0.024). Endoscopists' visual analogue scale scores showed that ease of echoendoscope introduction was significantly better in the midazolam group. There was no significant difference in overall patient cooperation during the procedure. There were no significant differences in introduction time, total procedure time, or patients' willingness to undergo the procedure under the same conditions. CONCLUSIONS: EUS of the esophagus and stomach without intravenous sedation is feasible for endoscopists and patients. Patients prefer intravenous administration of midazolam. Assessment of anxiety before EUS may indicate whether administration of midazolam can improve tolerance for the individual patient.
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