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Reddi DM, Barner LA, Burke W, Gao G, Grady WM, Liu JTC. Nondestructive 3D Pathology Image Atlas of Barrett Esophagus With Open-Top Light-Sheet Microscopy. Arch Pathol Lab Med 2023; 147:1164-1171. [PMID: 36596255 DOI: 10.5858/arpa.2022-0133-oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/04/2023]
Abstract
CONTEXT.— Anatomic pathologists render diagnosis on tissue samples sectioned onto glass slides and viewed under a bright-field microscope. This approach is destructive to the sample, which can limit its use for ancillary assays that can inform patient management. Furthermore, the subjective interpretation of a relatively small number of 2D tissue sections per sample contributes to low interobserver agreement among pathologists for the assessment (diagnosis and grading) of various lesions. OBJECTIVE.— To evaluate 3D pathology data sets of thick formalin-fixed Barrett esophagus specimens imaged nondestructively with open-top light-sheet (OTLS) microscopy. DESIGN.— Formalin-fixed, paraffin-embedded Barrett esophagus samples (N = 15) were deparaffinized, stained with a fluorescent analog of hematoxylin-eosin, optically cleared, and imaged nondestructively with OTLS microscopy. The OTLS microscopy images were subsequently compared with archived hematoxylin-eosin histology sections from each sample. RESULTS.— Barrett esophagus samples, both small endoscopic forceps biopsies and endoscopic mucosal resections, exhibited similar resolvable structures between OTLS microscopy and conventional light microscopy with up to a ×20 objective (×200 overall magnification). The 3D histologic images generated by OTLS microscopy can enable improved discrimination of cribriform and well-formed gland morphologies. In addition, a much larger amount of tissue is visualized with OTLS microscopy, which enables improved assessment of clinical specimens exhibiting high spatial heterogeneity. CONCLUSIONS.— In esophageal specimens, OTLS microscopy can generate images comparable in quality to conventional light microscopy, with the advantages of providing 3D information for enhanced evaluation of glandular morphologies and enabling much more of the tissue specimen to be visualized nondestructively.
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Affiliation(s)
- Deepti M Reddi
- From the Department of Laboratory Medicine and Pathology (Reddi, Liu), University of Washington, Seattle
| | - Lindsey A Barner
- Department of Mechanical Engineering (Barner, Gao, Liu), University of Washington, Seattle
| | - Wynn Burke
- Department of Medicine (Burke, Grady), University of Washington, Seattle
- The Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (Burke, Grady)
| | - Gan Gao
- Department of Mechanical Engineering (Barner, Gao, Liu), University of Washington, Seattle
| | - William M Grady
- Department of Medicine (Burke, Grady), University of Washington, Seattle
- The Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (Burke, Grady)
| | - Jonathan T C Liu
- From the Department of Laboratory Medicine and Pathology (Reddi, Liu), University of Washington, Seattle
- Department of Mechanical Engineering (Barner, Gao, Liu), University of Washington, Seattle
- Department of Bioengineering (Liu), University of Washington, Seattle
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Hirano Y, Kaneko H, Konishi T, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Daiko H, Itano O, Yasunaga H, Kitagawa Y. Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan. Ann Surg Oncol 2022; 29:8225-8234. [PMID: 35960454 DOI: 10.1245/s10434-022-12346-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/12/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear. OBJECTIVE The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer. METHODS Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders. RESULTS Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results. CONCLUSIONS EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan.
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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3
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Hoelzen JP, Sander KJ, Sesia M, Roy D, Rijcken E, Schnabel A, Struecker B, Juratli MA, Pascher A. Robotic-Assisted Esophagectomy Leads to Significant Reduction in Postoperative Acute Pain: A Retrospective Clinical Trial. Ann Surg Oncol 2022; 29:7498-7509. [PMID: 35854033 PMCID: PMC9550779 DOI: 10.1245/s10434-022-12200-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022]
Abstract
Background Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy. Methods A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints. Results A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001). Conclusions This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.
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Affiliation(s)
- Jens P Hoelzen
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany.
| | - Karl J Sander
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Matteo Sesia
- Department of Data Sciences and Operations, Marshall School of Business, University of Southern California, Los Angeles, CA, USA
| | | | - Emile Rijcken
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Mazen A Juratli
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
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4
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Li TT, Chang QY, Xiong LL, Chen YJ, Li QJ, Liu F, Wang TH. Patients with gastroenteric tumor after upper abdominal surgery were more likely to require rescue analgesia than lower abdominal surgery. BMC Anesthesiol 2022; 22:156. [PMID: 35606700 PMCID: PMC9125846 DOI: 10.1186/s12871-022-01682-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/25/2022] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To find out the reasons why patients still need to use rescue analgesics frequently after gastrointestinal tumor surgery under the patient-controlled intravenous analgesia (IV-PCA), and the different abdominal surgery patients using the difference of analgesics. METHODS A total of 970 patients underwent abdominal operation for gastrointestinal tumors were included. According whether patients used dezocine frequently for rescue analgesics within 2 days after surgery, they assigned into two groups: RAN group (Patients who did not frequently use rescue analgesia, 406 cases) and RAY group (Patients who frequently used rescue analgesia, 564 cases). The data collected included patient's characteristics, postoperative visual analogue scale (VAS), nausea and vomiting (PONV), and postoperative activity recovery time. RESULTS No differences were observed in the baseline characteristics. Compared with the RAN group, patients in the RAY group had a higher proportion of open surgery, upper abdominal surgery, VAS score at rest on the first 2 days after surgery and PONV, and a slower recovery of most postoperative activities. Under the current use of IV-PCA background, the proportion of rescue analgesics used by patients undergoing laparotomy and upper abdominal surgery was as high as 64.33% and 72.8%, respectively. Regression analysis showed that open surgery (vs laparoscopic surgery: OR: 2.288, 95% CI: 1.650-3.172) and the location of the tumor in the upper abdomen (vs lower abdominal tumor: OR: 2.738, 95% CI: 2.034-3.686) were influential factors for frequent salvage administration. CONCLUSIONS In our patient population, with our IV-PCA prescription for postoperative pain control, patient who underwent open upper abdominal surgery required more rescue postoperative analgesia.
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Affiliation(s)
- Ting-Ting Li
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Chengdu, 610041, Sichuan, China
| | - Quan-Yuan Chang
- Department of Anesthesiology, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Liu-Lin Xiong
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Chengdu, 610041, Sichuan, China
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Yan-Jun Chen
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Chengdu, 610041, Sichuan, China
| | - Qi-Jun Li
- Traditional Chinese Medicine, Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Fei Liu
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Chengdu, 610041, Sichuan, China.
| | - Ting-Hua Wang
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Chengdu, 610041, Sichuan, China.
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5
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Axley P, Mitchell R, Council L, Patel C, Tracht J, Collingwood R, Harrison D, Redden D, Beasely M, Kabir Baig KKR, Al Diffalha S, Peter S. Videoconference microscopy is a reliable alternative to conventional microscopy in the evaluation of Barrett's esophagus: Zooming into a new era. Dis Esophagus 2022; 35:6373273. [PMID: 34553220 DOI: 10.1093/dote/doab064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/18/2021] [Accepted: 08/22/2021] [Indexed: 12/11/2022]
Abstract
Telepathology, practicing pathology from a distance, allows experts to review cases without the need to transfer glass slides. Due to significant intra- and inter-observer variabilities in the histological evaluation of Barrett's esophagus (BE), current guidelines recommend expert consultation in cases of dysplasia. We aimed to determine whether telepathology using microscope videoconferencing can be reliably used for evaluation of BE. Biopsies from 62 patients with endoscopic findings of salmon colored mucosa extending ≥1 cm proximal to the gastroesophageal junction were randomly selected to represent benign esophagus, non-dysplastic BE, low-grade dysplasia, high-grade dysplasia, and adenocarcinoma. Three gastrointestinal-trained pathologists reviewed the cases via videoconference microscopy followed by conventional microscopy. Intra-observer and pairwise inter-observer agreements between the conventional microscopy and videoconference methodologies were calculated for each of the three pathologists using Fleiss-Cohen weighted kappa (K) analysis. The intra-observer agreement for each pathologist's assessment of videoconference microscopy and glass slide readings showed very good reliability (K = 0.94, 95% confidence interval = 0.89-0.99; 0.88, 95% confidence interval = 0.79-0.98; 0.93, 95% confidence interval = 0.90-0.97). Mean pairwise inter-observer agreement was 0.90 for videoconference and 0.91 for conventional microscopy. Diagnosis and grading of BE using videoconference microscopy show similar reliability as conventional microscopy. Based on our findings, we propose that videoconferencing pathology is a valid instrument for evaluating BE.
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Affiliation(s)
- Page Axley
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel Mitchell
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leona Council
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chirag Patel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica Tracht
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robin Collingwood
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Devin Harrison
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Redden
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Beasely
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Sameer Al Diffalha
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA
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6
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van der Wel MJ, Klaver E, Pouw RE, Brosens LAA, Biermann K, Doukas M, Huysentruyt C, Karrenbeld A, Ten Kate FJW, Kats-Ugurlu G, van der Laan J, van Lijnschoten I, Moll FCP, Offerhaus GJA, Ooms AHAG, Seldenrijk CA, Visser M, Tijssen JG, Meijer SL, Bergman JJGHM. Significant variation in histopathological assessment of endoscopic resections for Barrett's neoplasia suggests need for consensus reporting: propositions for improvement. Dis Esophagus 2021; 34:6294819. [PMID: 34100554 DOI: 10.1093/dote/doab034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 12/11/2022]
Abstract
Endoscopic resection (ER) is an important diagnostic step in management of patients with early Barrett's esophagus (BE) neoplasia. Based on ER specimens, an accurate histological diagnosis can be made, which guides further treatment. Based on depth of tumor invasion, differentiation grade, lymphovascular invasion, and margin status, the risk of lymph node metastases and local recurrence is judged to be low enough to justify endoscopic management, or high enough to warrant invasive surgical esophagectomy. Adequate assessment of these histological risk factors is therefore of the utmost importance. Aim of this study was to assess pathologist concordance on these histological features on ER specimens and evaluate causes of discrepancy. Of 62 challenging ER cases, one representative H&E slide and matching desmin and endothelial marker were digitalized and independently assessed by 13 dedicated GI pathologists from 8 Dutch BE expert centers, using an online assessment module. For each histological feature, concordance and discordance were calculated. Clinically relevant discordances were observed for all criteria. Grouping depth of invasion categories according to expanded endoscopic treatment criteria (T1a and T1sm1 vs. T1sm2/3), ≥1 pathologist was discrepant in 21% of cases, increasing to 45% when grouping diagnoses according to the traditional T1a versus T1b classification. For differentiation grade, lymphovascular invasion, and margin status, discordances were substantial with 27%, 42%, and 32% of cases having ≥1 discrepant pathologist, respectively. In conclusion, histological assessment of ER specimens of early BE cancer by dedicated GI pathologists shows significant discordances for all relevant histological features. We present propositions to improve definitions of diagnostic criteria.
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Affiliation(s)
- M J van der Wel
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - L A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - M Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Huysentruyt
- Department of Pathology, Stichting PAMM, Catharina Hospital, Eindhoven, The Netherlands
| | - A Karrenbeld
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - F J W Ten Kate
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - J van der Laan
- Department of Pathology, Haga Hospital, The Hague, The Netherlands
| | - I van Lijnschoten
- Department of Pathology, Stichting PAMM, Catharina Hospital, Eindhoven, The Netherlands
| | - F C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A H A G Ooms
- Department of Pathology, Pathan BV, St. Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, The Netherlands
| | - J G Tijssen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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7
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Profiling patient-reported symptom recovery from oesophagectomy for patients with oesophageal squamous cell carcinoma: a real-world longitudinal study. Support Care Cancer 2021; 30:2661-2670. [PMID: 34817693 DOI: 10.1007/s00520-021-06711-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/18/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Oesophageal squamous cell carcinoma (ESCC) patients have severe symptom burden after oesophagectomy; however, longitudinal studies of symptom recovery after surgery are scarce. This study used longitudinal patient-reported outcome (PRO)-based symptoms to identify severe symptoms and profile symptom recovery from surgery in patients undergoing oesophagectomy. METHODS Oesophageal cancer patients (N = 327) underwent oesophagectomy were consecutively included between April 2019 and March 2020. Data were extracted from the Sichuan Cancer Hospital's Esophageal Cancer Case Management Registration Database. Symptom assessment time points were pre-surgery and 1, 3, 5, 7, 14, 21, 30, and 90 days post-surgery using the Chinese version of the MD Anderson Symptom Inventory. And each symptom was rated on an 11-point scale, with 0 being 'not present' and 10 being 'as bad as you can imagine'. The symptom recovery trajectories were profiled using mixed effect models and Kaplan-Meier analysis. RESULTS The most-severe symptoms on day 1 after oesophagectomy were pain, fatigue, dry mouth, disturbed sleep, and distress. The severity of symptoms peaked on day 1 after surgery. The top two symptoms were fatigue (mean: 5.44 [SD 1.88]) and pain (mean: 5.23 [SD 1.29]). Fatigue was more severe 90 days after surgery than at baseline (mean: 1.77 [SD 1.47] vs 0.65 [SD 1.05]; P < .0001). Disturbed sleep and distress persisted from pre-surgery to 90 days post-surgery; average sleep recovery time was up to 20 days, and 50.58% of patients had sleep disturbances 90 days post-surgery. CONCLUSIONS Early post-operative pain management after oesophagectomy should be considered. Characteristics and intervention strategies of post-operative fatigue, distress, and disturbed sleep in oesophageal cancer patients warrant further studies.
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8
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Feenstra ML, Ten Hoope W, Hermanides J, Gisbertz SS, Hollmann MW, van Berge Henegouwen MI, Eshuis WJ. Optimal Perioperative Pain Management in Esophageal Surgery: An Evaluation of Paravertebral Analgesia. Ann Surg Oncol 2021; 28:6321-6328. [PMID: 34050429 PMCID: PMC8460583 DOI: 10.1245/s10434-021-10172-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
Background For esophagectomy, thoracic epidural analgesia (TEA) is the standard of care for perioperative pain management. Although effective, TEA is associated with moderate to serious adverse events such as hypotension and neurologic complications. Paravertebral analgesia (PVA) may be a safe alternative. The authors hypothesized that TEA and PVA are similar in efficacy for pain treatment in thoracolaparoscopic Ivor Lewis esophagectomy. Methods This retrospective cohort study compared TEA with PVA in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In this study, TEA consisted of continuous epidural bupivacaine and sufentanil infusion with a patient-controlled bolus function. In PVA, the catheter was inserted by the surgeon under thoracoscopic vision during surgery. Administration of PVA consisted of continuous paravertebral bupivacaine infusion after a bolus combined with patient-controlled analgesia using intravenous morphine. The primary outcome was the median highest recorded Numeric Pain Rating Scale (NRS) during the 3 days after surgery. The secondary outcomes were vasopressor consumption, fluid administration, and length of hospital stay. Results In both groups, the median highest recorded NRS was 4 or lower during the first three postoperative days. The patients with PVA had a higher overall NRS (mean difference, 0.75; 95% confidence interval 0.49–1.44). No differences were observed in any of the other secondary outcomes. Conclusion For the patients undergoing thoracolaparoscopic Ivor Lewis esophagectomy, TEA was superior to PVA, as measured by NRS during the first three postoperative days. However, both modes provided adequate analgesia, with a median highest recorded NRS of 4 or lower. These results could form the basis for a randomized controlled trial. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10172-1.
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Affiliation(s)
- Minke L Feenstra
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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9
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Pinto E, Nardi MT, Marchi R, Cavallin F, Alfieri R, Saadeh L, Cagol M, Baldan I, Saraceni E, Parotto M, Baratto F, Caberlotto C, Vianello A, Castoro C, Scarpa M. QOLEC2: a randomized controlled trial on nutritional and respiratory counseling after esophagectomy for cancer. Support Care Cancer 2020; 29:1025-1033. [PMID: 32572611 PMCID: PMC7307937 DOI: 10.1007/s00520-020-05573-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/11/2020] [Indexed: 01/18/2023]
Abstract
Background Esophagectomy for cancer strongly impairs quality of life. The aim of this trial was to evaluate the effect of the nutritional and respiratory counseling on postoperative quality of life. Methods At hospital discharge, patients were randomized into four groups receiving respectively: nutritional and respiratory counseling, nutritional counseling alone, respiratory counseling alone, or standard care. The main endpoint was the impairment in quality of life in the first month after surgery. Linear mixed effect models were estimated to assess mean score differences (MDs) in quality of life scores. Results Patients receiving nutritional counseling reported less appetite loss (MD − 17.7, 95% CI − 32.2 to −3.3) than those not receiving nutritional counseling at 1 month after surgery. Dyspnea was similar between patients receiving vs. those not receiving respiratory counseling (MD − 3.1, 95% CI − 10.8 to 4.6). Global quality of life was clinically similar between patients receiving vs. those not receiving nutritional counseling over time (MD 0.9, 95% CI − 5.5 to 7.3), as well as in patients receiving vs. those not receiving respiratory counseling over time (MD 0.7, 95% CI − 5.9 to 7.2). Conclusions Intensive postoperative care does not affect global quality of life even if nutritional counseling reduced appetite loss. Electronic supplementary material The online version of this article (10.1007/s00520-020-05573-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eleonora Pinto
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Maria Teresa Nardi
- Nutritional Support Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Rita Marchi
- Respiratory Intensive Care Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - Francesco Cavallin
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Rita Alfieri
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Luca Saadeh
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Matteo Cagol
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Ilaria Baldan
- Nutritional Support Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | | | - Matteo Parotto
- Intensive Care Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | - Fabio Baratto
- Intensive Care Unit (ISTAR 2), Azienda Ospedaliera di Padova, Padua, Italy
| | - Cristina Caberlotto
- Oesophageal and Digestive Tract Surgical Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Andrea Vianello
- Respiratory Intensive Care Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - Carlo Castoro
- Department. of Upper GI Surgery, Humanitas Research Hospital-Humanitas University, Rozzano, Italy
| | - Marco Scarpa
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy.
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10
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Klaver E, van der Wel M, Duits L, Pouw R, Seldenrijk K, Offerhaus J, Visser M, Ten Kate F, Biermann K, Brosens L, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan J, van Lijnschoten I, Moll F, Ooms A, Tijssen J, Meijer S, Bergman J. Performance of gastrointestinal pathologists within a national digital review panel for Barrett's oesophagus in the Netherlands: results of 80 prospective biopsy reviews. J Clin Pathol 2020; 74:48-52. [PMID: 32467320 PMCID: PMC7788478 DOI: 10.1136/jclinpath-2020-206511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/17/2020] [Accepted: 05/01/2020] [Indexed: 11/03/2022]
Abstract
AIMS The histopathological diagnosis of low-grade dysplasia (LGD) in Barrett's oesophagus (BO) is associated with poor interobserver agreement and guidelines dictate expert review. To facilitate nationwide expert review in the Netherlands, a web-based digital review panel has been set up, which currently consists of eight 'core' pathologists. The aim of this study was to evaluate if other pathologists from the Dutch BO expert centres qualify for the expert panel by assessing their performance in 80 consecutive LGD reviews submitted to the panel. METHODS Pathologists independently assessed digital slides in two phases. Both phases consisted of 40 cases, with a group discussion after phase I. For all cases, a previous consensus diagnosis made by five core pathologists was available, which was used as reference. The following criteria were used: (1) percentage of 'indefinite for dysplasia' diagnoses, (2) percentage agreement with consensus diagnosis and (3) proportion of cases with a consensus diagnosis of dysplasia underdiagnosed as non-dysplastic. Benchmarks were based on scores of the core pathologists. RESULTS After phase I, 1/7 pathologists met the benchmark score for all quality criteria, yet three pathologists only marginally failed the agreement with consensus diagnosis (score 68.3%, benchmark 69%). After a group discussion and phase II, 5/6 remaining aspirant panel members qualified with all scores within the benchmark range. CONCLUSIONS The Dutch BO review panel now consists of 14 pathologists, who-after structured assessments and group discussions-can be considered homogeneous in their review of biopsies with LGD.
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Affiliation(s)
- Esther Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Myrtle van der Wel
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands.,Department of Pathology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Lucas Duits
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Roos Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, Pathologie-DNA BV, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Johan Offerhaus
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Mike Visser
- Department of Pathology, Symbiant BV, Alkmaar, The Netherlands
| | - Fiebo Ten Kate
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Michael Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | | | | | | | | | - Freek Moll
- Department of Pathology, Isala Klinieken, Zwolle, The Netherlands
| | - Ariadne Ooms
- Department of Pathology, Pathan BV, Sint Franciscus Vlietland Groep, Rotterdam, The Netherlands
| | - Jan Tijssen
- Department of Cardiology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
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11
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van der Wel MJ, Coleman HG, Bergman JJGHM, Jansen M, Meijer SL. Histopathologist features predictive of diagnostic concordance at expert level among a large international sample of pathologists diagnosing Barrett's dysplasia using digital pathology. Gut 2020; 69:811-822. [PMID: 31852770 DOI: 10.1136/gutjnl-2019-318985] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Guidelines mandate expert pathology review of Barrett's oesophagus (BO) biopsies that reveal dysplasia, but there are no evidence-based standards to corroborate expert reviewer status. We investigated BO concordance rates and pathologist features predictive of diagnostic discordance. DESIGN Pathologists (n=51) from over 20 countries assessed 55 digitised BO biopsies from across the diagnostic spectrum, before and after viewing matched p53 labelling. Extensive demographic and clinical experience data were obtained via online questionnaire. Reference diagnoses were obtained from a review panel (n=4) of experienced Barrett's pathologists. RESULTS We recorded over 6000 case diagnoses with matched demographic data. Of 2805 H&E diagnoses, we found excellent concordance (>70%) for non-dysplastic BO and high-grade dysplasia, and intermediate concordance for low-grade dysplasia (42%) and indefinite for dysplasia (23%). Major diagnostic errors were found in 248 diagnoses (8.8%), which reduced to 232 (8.3%) after viewing p53 labelled slides. Demographic variables correlating with diagnostic proficiency were analysed in multivariate analysis, which revealed that at least 5 years of professional experience was protective against major diagnostic error for H&E slide review (OR 0.48, 95% CI 0.31 to 0.74). Working in a non-teaching hospital was associated with increased odds of major diagnostic error (OR 1.76, 95% CI 1.15 to 2.69); however, this was neutralised when pathologists viewed p53 labelled slides. Notably, neither case volume nor self-identifying as an expert predicted diagnostic proficiency. Extrapolating our data to real-world case prevalence suggests that 92.3% of major diagnostic errors are due to overinterpreting non-dysplastic BO. CONCLUSION Our data provide evidence-based criteria for diagnostic proficiency in Barrett's histopathology.
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Affiliation(s)
| | - Helen G Coleman
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | | | | | - Sybren L Meijer
- Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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van der Wel MJ, Klaver E, Duits LC, Pouw RE, Seldenrijk CA, Offerhaus G, Visser M, Ten Kate F, Biermann K, Brosens L, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan JS, van Lijnschoten G, Moll F, Ooms A, Tijssen JG, Bergman J, Meijer SL. Adherence to pre-set benchmark quality criteria to qualify as expert assessor of dysplasia in Barrett's esophagus biopsies - towards digital review of Barrett's esophagus. United European Gastroenterol J 2019; 7:889-896. [PMID: 31428413 PMCID: PMC6683647 DOI: 10.1177/2050640619853441] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
Background Dysplasia assessment of Barrett’s esophagus biopsies is associated with low
observer agreement; guidelines advise expert review. We have developed a
web-based review panel for dysplastic Barrett’s esophagus biopsies. Objective The purpose of this study was to test if 10 gastrointestinal pathologists
working at Dutch Barrett’s esophagus expert centres met pre-set benchmark
scores for quality criteria. Methods Ten gastrointestinal pathologists twice assessed 60 digitalized Barrett’s
esophagus cases, enriched for dysplasia; then randomised (7520 assessments).
We tested predefined benchmark quality criteria: (a) percentage of
‘indefinite for dysplasia’ diagnoses, benchmark score ≤14% for all cases,
≤16% for dysplastic subset, (b) intra-observer agreement; benchmark score
≥0.66/≥0.39, (c) percentage agreement with ‘gold standard diagnosis’;
benchmark score ≥82%/≥73%, (d) proportion of cases with high-grade dysplasia
underdiagnosed as non-dysplastic Barrett’s esophagus; benchmark score ≤1/78
(≤1.28%) assessments for dysplastic subset. Results Gastrointestinal pathologists had seven years’ Barrett’s
esophagus-experience, handling seven Barrett’s esophagus-cases weekly. Three
met stringent benchmark scores; all cases and dysplastic subset, three met
extended benchmark scores. Four pathologists lacked one quality criterion to
meet benchmark scores. Conclusion Predefined benchmark scores for expert assessment of Barrett’s esophagus
dysplasia biopsies are stringent and met by some gastrointestinal
pathologists. The majority of assessors however, only showed limited
deviation from benchmark scores. We expect further training with group
discussions will lead to adherence of all participating gastrointestinal
pathologists to quality criteria, and therefore eligible to join the review
panel.
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Affiliation(s)
- M J van der Wel
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA BV, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Gja Offerhaus
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, Zaandam, the Netherlands
| | - Fjw Ten Kate
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laa Brosens
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Doukas
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - C Huysentruyt
- Department of Pathology, Stichting PAMM, Eindhoven, The Netherlands
| | - A Karrenbeld
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, Academic Medical Center Groningen, Groningen, The Netherlands
| | - J S van der Laan
- Department of Pathology, Haga Hospital, The Hague, The Netherlands
| | | | - Fcp Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Ahag Ooms
- Department of Pathology, Pathan BV, St. Fransiscus Vlietland Hospital, Rotterdam, the Netherlands
| | - J G Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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13
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Chapter 2: Role of pathologic confirmation for Barrett′s esophagus and dysplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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14
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van der Wel MJ, Duits LC, Klaver E, Pouw RE, Seldenrijk CA, Offerhaus GJA, Visser M, ten Kate FJW, Tijssen JG, Bergman JJGHM, Meijer SL. Development of benchmark quality criteria for assessing whole-endoscopy Barrett's esophagus biopsy cases. United European Gastroenterol J 2018; 6:830-837. [PMID: 30023060 PMCID: PMC6047285 DOI: 10.1177/2050640618764710] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/12/2018] [Indexed: 12/20/2022] Open
Abstract
Background Dysplasia in Barrett's esophagus (BE) biopsies is associated with low
observer agreement among general pathologists. Therefore, expert review is
advised. We are developing a web-based, national expert review panel for
histological review of BE biopsies. Objective The aim of this study was to create benchmark quality criteria for future
members. Methods Five expert BE pathologists, with 10–30 years of BE experience, weekly
handling 5–10 cases (25% dysplastic), assessed a case set of 60 digitalized
cases, enriched for dysplasia. Each case contained all slides from one
endoscopy (non-dysplastic BE (NDBE), n = 21; low-grade
dysplasia (LGD), n = 20; high-grade dysplasia (HGD),
n = 19). All cases were randomized and assessed twice
followed by group discussions to create a consensus diagnosis. Outcome
measures: percentage of ‘indefinite for dysplasia’ (IND) diagnoses,
intra-observer agreement, and agreement with the consensus ‘gold standard’
diagnosis. Results Mean percentage of IND diagnoses was 8% (3–14%) and mean intra-observer
agreement was 0.84 (0.66–1.02). Mean agreement with the consensus diagnosis
was 90% (95% prediction interval (PI) 82–98%). Conclusion Expert pathology review of BE requires the scoring of a limited number of IND
cases, consistency of assessment and a high agreement with a consensus gold
standard diagnosis. These benchmark quality criteria will be used to assess
the performance of other pathologists joining our panel.
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Affiliation(s)
- MJ van der Wel
- Department of Pathology,
Academic
Medical Center, Amsterdam, The
Netherlands
- Department of Gastroenterology and
Hepatology,
Academic
Medical Center, Amsterdam, The
Netherlands
- Myrtle J van der Wel, AMC, Meibergdreef 9,
Amsterdam 1105, AZ, The Netherlands.
| | - LC Duits
- Department of Gastroenterology and
Hepatology,
Academic
Medical Center, Amsterdam, The
Netherlands
| | - E Klaver
- Department of Gastroenterology and
Hepatology,
Academic
Medical Center, Amsterdam, The
Netherlands
| | - RE Pouw
- Department of Gastroenterology and
Hepatology,
Academic
Medical Center, Amsterdam, The
Netherlands
| | - CA Seldenrijk
- Pathology–DNA, Department of Pathology,
St. Antonius Hospital, Nieuwegein, The Netherlands
| | - GJA Offerhaus
- Department of Pathology, University
Medical Center, Utrecht, The Netherlands
| | - M Visser
- Symbiant BV, Department of Pathology,
Alkmaar, The Netherlands
| | - FJW ten Kate
- Department of Pathology, University
Medical Center, Utrecht, The Netherlands
| | - JG Tijssen
- Department of Cardiology,
Academic
Medical Center, Amsterdam, The
Netherlands
| | - JJGHM Bergman
- Department of Gastroenterology and
Hepatology,
Academic
Medical Center, Amsterdam, The
Netherlands
| | - SL Meijer
- Department of Pathology,
Academic
Medical Center, Amsterdam, The
Netherlands
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