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Endoscopy of the Upper Gastrointestinal Tract

Article  in  New England Journal of Medicine · January 2000

DOI: 10.1056/NEJM199912023412306 · Source: PubMed

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 The New Eng land Jour nal of Medicine

Review Articles

Medical Progress ing staff, a day off from work by the patient, and an
escort to accompany the patient home from the pro-
cedure. Current interest in endoscopy without se-
dation has been stimulated by the development of
E NDOSCOPY OF THE U PPER ultrathin endoscopes. Whereas standard diagnostic
G ASTROINTESTINAL T RACT gastroscopes are 9 mm in diameter and endoscopes
used to perform therapeutic procedures in the upper
gastrointestinal tract are typically 11 mm in diameter
JACQUES VAN DAM, M.D., PH.D.,
(and contain a wide-caliber accessory channel), new-
AND WILLIAM R. BRUGGE, M.D.
er, ultrathin endoscopes have an outer diameter of
5.3 mm (for fiberoptic endoscopes) or 5.9 mm (for
video endoscopes). Such instruments can be insert-

T
HE rapid development of high-technology ed either transorally or transnasally with reasonable
procedures has come at a time when the abil- ease. Although not yet in widespread use, ultrathin
ity of the U.S. health care system to provide endoscopes may permit endoscopy to be performed
expensive services to all patients is increasingly con- without sedation, thereby reducing the direct and
strained. The inverse relation between expanding med- indirect costs of the procedure.
ical achievement and contracting resources for health
care delivery has stimulated an evaluation of the ap- DIAGNOSIS AND TREATMENT
propriate use of endoscopic procedures. Serious con- OF NONVARICEAL BLEEDING OF THE
cern about the effects of a reduction in health care UPPER GASTROINTESTINAL TRACT
costs on the quality of patient care has led to critical Hemorrhage of the upper gastrointestinal tract is
analysis of endoscopic practice.1-3 There appears, how- a common reason for emergency medical care and
ever, to be little consensus on the appropriate uses hospitalization. Despite the widespread use of hista-
of endoscopic procedures. In prospective trials in- mine H2–receptor antagonists and proton-pump in-
volving primary care physicians and more than 8000 hibitors, bleeding from a peptic ulcer (Fig. 1) remains
patient visits, both underuse and overuse of upper the most common cause of upper gastrointestinal
gastrointestinal endoscopy were reported.2,3 The es- bleeding, accounting for approximately 50 percent
timated rates of underuse and overuse of endoscopy of cases of severe upper gastrointestinal hemorrhage.
were approximately the same — 5 percent — which Other common causes of upper gastrointestinal bleed-
suggests that the criteria by which patients are se- ing are esophageal or gastric varices, Mallory–Weiss
lected for endoscopic procedures can be improved. tears, and vascular malformations. Endoscopy is the
One way to improve the safety and reduce the preferred investigative procedure for upper gastroin-
cost of endoscopy is to perform procedures without testinal bleeding because of its accuracy, low rate of
sedation.4-10 The ability to provide sedation and an- complications, and potential for therapeutic inter-
algesia safely and effectively and to ensure the clini- vention.12 Rates of hemostasis that resulted from a
cal stability and comfort of the patient have long first endoscopic procedure exceeded 94 percent in
been important components of the endoscopic pro- most large studies in which standardized techniques
cedure. 11 However, because a substantial proportion were used for thermocoagulation of bleeding lesions.13
of procedure-related complications are due to seda- Methods of achieving hemostasis include multipolar
tion and analgesia, the performance of endoscopy electrocoagulation, injection therapy, endoscopic la-
without sedation would appear to be a worthwhile ser therapy, hemoclipping,14 and ligation.15 Endo-
goal. Endoscopy without sedation would also reduce scopic ligation was first used for the treatment of
costs substantially by eliminating the need for seda- bleeding esophageal varices in 1988,16 but its tech-
tives, hemodynamic monitoring during the proce- nical simplicity as compared with other endoscopic
dure, time in the recovery room, some of the nurs- methods of achieving hemostasis has led to its use
in treating a variety of upper gastrointestinal lesions,
including Dieulafoy’s lesions, duodenal ulcers, gas-
From the Division of Gastroenterology, Department of Medicine,
tric angiodysplasia, and Mallory–Weiss tears.15
Brigham and Women’s Hospital (J.V.D.), Massachusetts General Hospital Endoscopic therapy that is performed within 24
(W.R.B.), and Harvard Medical School (J.V.D., W.R.B.) — all in Boston. hours after admission is associated with reductions
Address reprint requests to Dr. Van Dam at Brigham and Women’s Hospi-
tal, 75 Francis St., Boston, MA 02115. in the length of hospital stay and in the risk of re-
©1999, Massachusetts Medical Society. current bleeding.17 After bleeding from ulcers is con-

1738 · Dec em b er 2 , 19 9 9
 MED ICA L PROGR ES S

DIAGNOSIS AND TREATMENT

OF VARICEAL BLEEDING OF THE UPPER
GASTROINTESTINAL TRACT
Variceal hemorrhage is the most serious complica-
tion of portal hypertension and occurs in one third
of patients with esophageal varices. The 30 to 50
percent mortality rate that is associated with variceal
bleeding has challenged endoscopists to design im-
proved methods of treating active hemorrhage. Up-
per gastrointestinal endoscopy, performed by an ex-
perienced endoscopist, should be the initial diagnostic
test after the patient’s condition has stabilized. En-
doscopic therapy consists of variceal band ligation or
injection sclerotherapy.
Until recently, injection sclerotherapy was consid-
ered the endoscopic treatment of choice for control-
Figure 1. Endoscopic Image of a Gastric Ulcer with a Visible ling active variceal hemorrhage.23 Sclerotherapy is suc-
Vessel. cessful in controlling active bleeding in more than
90 percent of patients and has been shown to reduce
the frequency and severity of recurrent bleeding.24
Sclerotherapy is performed by injecting a sclerosant
trolled endoscopically, the rate of recurrent bleeding (e.g., ethanolamine oleate, sodium tetradecyl sulfate,
is 15 to 20 percent. Endoscopic retreatment was com- polidocanol, morrhuate sodium, mecrylate, or etha-
pared with surgery in a prospective trial involving nol) into the varix to produce thrombosis or inject-
3473 adults with bleeding peptic ulcers who had been ing it adjacent to the varix to induce submucosal fi-
admitted to a single medical center.18 The success brosis. Complications of sclerotherapy include fever,
rate of an initial endoscopic procedure to achieve he- chest pain, bacteremia, esophageal ulceration, bleed-
mostasis in patients with severe upper gastrointesti- ing, stricture formation, dysphagia, and perforation.25
nal bleeding was high; the rate of rebleeding was In patients in whom endoscopic therapy of bleeding
only 8.7 percent. Ninety-two patients in whom he- esophageal or gastric varices fails, good immediate,
mostasis was achieved with an initial procedure but short-term control of bleeding may be achieved by
who later had recurrent bleeding were randomly as- transjugular intrahepatic portosystemic shunting.26
signed to undergo either a second endoscopic pro- Endoscopic band ligation of varices is now consid-
cedure (48 patients) or surgery (44 patients). As com- ered to be the treatment of choice for patients with
pared with the patients randomly assigned to surgery, bleeding esophageal varices.27 The technique of en-
the patients with recurrent bleeding who were treat- doscopic ligation is similar to that used to treat in-
ed with a second endoscopic procedure had a reduced ternal hemorrhoids, in which bands are used to ligate
need for surgery without a concomitant increase in the base of the hemorrhoid or varix. Results of sev-
the risk of death and had a lower rate of complica- eral randomized, controlled trials in which endoscop-
tions. The authors concluded that in the minority of ic variceal ligation was compared with sclerotherapy
patients in whom hemostasis was not achieved by an suggest that variceal band ligation controls active
initial endoscopy, at least one more attempt at endo- bleeding in 80 to 90 percent of patients; it also re-
scopic therapy was preferable to surgery.18 quires fewer treatment sessions and results in fewer
At the other end of the spectrum, some patients complications than sclerotherapy.23,28,29 A meta-analy-
can be assigned to outpatient treatment of acute up- sis has confirmed the superiority of endoscopic liga-
per gastrointestinal hemorrhage on the basis of the tion over sclerotherapy with regard to rebleeding,
early identification of favorable clinical and endo- local complications, time to variceal obliteration, and
scopic characteristics.19,20 In prospective analyses, he- even short-term survival.30 In addition, variceal band
modynamically stable patients in whom endoscopy ligation may be more effective than medical therapy
did not show features suggestive of a high risk of that involves the use of the beta-adrenergic antago-
rebleeding — such as arterial bleeding, an ulcer nist propranolol for the primary prevention of bleed-
greater than 2 cm in diameter, an adherent clot, a ing in patients with large esophageal varices.31
visible vessel, esophageal varices, or portal hyper-
tensive gastropathy — were safely discharged from ENDOSCOPY OF THE SMALL INTESTINE
acute care after medical treatment was begun.17,21,22 After a careful history taking has eliminated com-
This strategy has the potential to reduce costs con- mon causes of gastrointestinal blood loss and the
siderably in the treatment of upper gastrointestinal results of upper endoscopy and colonoscopy are
bleeding.17 found to be negative, an examination of the small

Vol ume 341 Numb e r 23 · 1739

 The New Eng land Jour nal of Medicine

intestine is usually performed. The small intestine ing who underwent push enteroscopy after negative
can be evaluated by endoscopy in three ways: push results were obtained on upper gastrointestinal en-
enteroscopy, operative endoscopy, or sonde (passive) doscopy and colonoscopy (or in whom bleeding per-
enteroscopy. sisted despite treatment of potential sources of gas-
In push enteroscopy, the tip of a long endoscope trointestinal bleeding detected on endoscopy), the
(a colonoscope, pediatric colonoscope, or specially most common finding was angiodysplasia (13 pa-
designed enteroscope) is passed beyond the ligament tients, or 45 percent), which was treated with elec-
of Treitz. The push-enteroscopic technique does not trocautery.34 Twenty of the 29 patients had received
permit visualization of the distal portions of the small transfusions (at a mean of 8 units per patient) in the
intestine. In a study of 55 patients with occult gas- year preceding the enteroscopy. In the year after en-
trointestinal bleeding, push enteroscopy led to the teroscopy, their transfusion requirements decreased
detection of the site of bleeding in 35 patients (64 substantially, and 4 of 13 treated patients (31 per-
percent), and surprisingly, 21 of the 35 patients (60 cent) required no additional blood transfusions. Thus,
percent) had lesions located proximal to the ligament the outcome in some patients with gastrointestinal
of Treitz.32 In asymptomatic patients with iron de- bleeding of initially obscure origin was improved af-
ficiency who have had a negative result on colonos- ter push enteroscopy.
copy, the most efficient and cost-effective approach In hospitals in which push enteroscopy is not avail-
to evaluate the patient further was recently found to able, the next-best method for evaluating bleeding
be enteroscopy.33 The use of an enteroscope rather from the small intestine is surgical endoscopy, dur-
than a gastroscope in this group of patients increased ing which a surgeon advances the endoscope manu-
the proportion in whom diagnoses were made from ally through the surgically exposed intestine. Unlike
41 percent to 67 percent and did so at a lower cost. either push or sonde enteroscopy, intraoperative en-
In general, the farther the enteroscope is advanced doscopy permits visualization of the entire length of
into the small intestine, the more likely it is that a di- small-bowel mucosa in the majority of cases. Intra-
agnosis will be made. Figure 2 shows a small-bowel operative endoscopy may be performed with a stand-
arteriovenous malformation detected by enteroscopy. ard gastroscope, colonoscope (pediatric, if available),
Once identified, potential sources of bleeding can or enteroscope.
be treated by an endoscopic method. Treatment is typ- The third method of small-bowel endoscopy is
ically accomplished with either a neodymium:yttrium– sonde enteroscopy, during which the tip of a small-
aluminum–garnet (Nd:YAG) laser or a bipolar elec- caliber enteroscope is allowed to move along the
trocautery unit with a modified, extra-long probe.34 small intestine passively. The instrument is extremely
Among 29 patients with occult gastrointestinal bleed- flexible, with a length that varies from 270 to 400 cm.
The instrument is inserted through the nose or the
mouth, depending on the diameter of the endoscope
and the preference of the endoscopist. Unlike push
enteroscopy, the sonde method allows visualization of
the distal portions of the small intestine but offers lit-
tle or no therapeutic capability. Inspection of the mu-
cosa of the small intestine is performed on withdrawal
of the enteroscope. Because most sonde enteroscopes
do not permit (or have limited) deflection of the tip,
and because reinsertion is not an option, the entero-
scope must be withdrawn slowly and the bowel must
be kept insufflated throughout the procedure.
DIAGNOSIS AND TREATMENT
OF NONMALIGNANT DISEASES OF THE
UPPER GASTROINTESTINAL TRACT
Subepithelial Lesions
Subepithelial or extraluminal lesions are sometimes
detected incidentally during contrast radiography or
upper gastrointestinal endoscopy. Endoscopy per-
mits visualization of the mucosal aspect of the le-
Figure 2. Small-Bowel Enteroscopy. sion but does not allow evaluation of the depth or
A jejunal arteriovenous malformation was detected by small- overall size of the lesion. In addition, with endosco-
bowel enteroscopy in a patient undergoing evaluation for a
previously obscure cause of iron-deficiency anemia and stools
py one often cannot distinguish lesions in or involv-
that were positive for occult blood. Prior esophagogastro- ing the submucosa from lesions involving the other
duodenoscopy and colonoscopy were negative. layers of the wall of the gastrointestinal tract or ad-

1740 · Decem b er 2 , 19 9 9
 MED IC A L PROGR ES S

jacent, extrinsic (extraluminal) lesions. Endoscopic

biopsies can be used for diagnosis only rarely, be-
cause they sample the mucosa but not the deeper
layers of the gastrointestinal tract wall.
The prevalence of subepithelial lesions is difficult to
assess, because most are asymptomatic and are found
incidentally during an evaluation for other reasons.35
The most common lesions of the upper gastrointes-
tinal tract that present as subepithelial masses are lei-
omyomas, which are found in the esophagus in up to
5 percent of autopsy specimens36 and in the stomach
in 50 percent of patients older than 50 years of age.37
Other abnormalities that present as subepithelial le-
sions are lipomas, duplication cysts, carcinoid tumors,
varices, and extrinsic compression by a normal adja-
cent organ. In the past, surgical exploration was the
standard method used for diagnosing (and treating)
subepithelial lesions, but endoscopic ultrasonogra-
phy has recently emerged as a new endoscopic meth-
od of determining the nature of subepithelial lesions
in the upper gastrointestinal tract. A
Endoscopic ultrasonography is perhaps the most
noteworthy advance in endoscopic technology in the
past 20 years. It combines the diagnostic imaging ca-
pability of ultrasonography with the access afforded
by endoscopy. The composite instrumentation per-
mits the placement of a piezoelectric transducer di-
rectly adjacent to the target tissue, thereby obviating
the need to transmit sound waves through mediums
that attenuate sound, such as air in the lungs, gas in
the bowel, or bone, as is often the case with standard
transcutaneous ultrasonography. This technique makes
possible high-resolution, close-proximity imaging of
the gastrointestinal tract, elucidation of the mural
histology of the gastrointestinal tract (the mucosa,
submucosa, muscularis propria, and adventitia or se-
rosa), and imaging of adjacent, extraluminal, or ret-
roperitoneal structures that cannot be visualized as
clearly by more conventional imaging methods.38-40
Endoscopic ultrasonography is an essential adjunct
to endoscopy for the diagnosis of subepithelial le- B
sions. Scanning at 20 MHz with the use of endo-
scopic ultrasound probes that can be passed through Figure 3. Endoscopic Ultrasonography.
the accessory channel of a standard endoscope pro- Panel A shows a normal gastric wall as imaged by endoscopic
vides high-resolution images and has been used to ultrasonography. The ultrasound transducer is incorporated
into the tip of the endoscope. The gastric wall is imaged as a
evaluate patients with benign subepithelial lesions five-layer structure with alternating hyperechoic and hypo-
and large gastric folds.41 Scanning with ultrasound echoic layers. The stomach has been filled with water, and a
of lower frequencies (5.0 MHz and 7.5 MHz) per- water-filled latex balloon surrounds the ultrasound transducer
mits the visualization of organs and lesions extrinsic to aid in acoustic coupling to the target structure. Panel B
shows an endosonogram of a 2.1-cm-by-1.2-cm gastric mass
to the gastrointestinal tract wall. The size and loca- (arrow). The mass arises from the third hyperechoic gastric-
tion of subepithelial tumors can be clearly elucidated wall layer (the submucosa). The gastric mucosa can be seen
(Fig. 3). In the majority of cases, the clinical care of overlying the lesion, and the muscularis propria and serosa can
patients is changed as a result of the information ob- be seen beneath the lesion. The differential diagnosis for the
tained by endoscopic ultrasonography.42,43 mass includes lipoma, carcinoid tumor, and pancreatic rest.

Barrett’s Esophagus
Barrett’s esophagus is characterized by a metaplas-
tic change of any length in the esophageal epithelium;

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 The New Eng land Jour nal of Medicine

it is recognizable during endoscopy and can be con-

firmed histologically as intestinal metaplasia.44 There
is considerable controversy regarding its precise def-
inition, however.45 It is a consequence of long-stand-
ing acid reflux, which is found in 8 to 20 percent of
patients who undergo upper gastrointestinal endos-
copy for symptoms of gastroesophageal reflux dis-
ease.46 Barrett’s esophagus is a precursor of adeno-
carcinoma of the esophagus, the incidence of which
has been increasing over the past 20 years.47,48
Recent practice guidelines offered by the Ameri-
can College of Gastroenterology suggest that pa-
tients with long-standing symptoms of gastroesoph-
ageal reflux, particularly patients older than 50 years
of age, should undergo upper gastrointestinal endos-
copy to determine whether Barrett’s esophagus is
present.44 A recent population-based, case–control
study found a strong causal relation between gastro-
esophageal reflux and esophageal adenocarcinoma.49
The care of patients with Barrett’s esophagus should
include upper gastrointestinal endoscopy and muco-
sal biopsies performed at time intervals determined A
by the presence and grade of dysplasia.44,50 Once
Barrett’s esophagus has been detected, the patient’s
condition should be monitored even if the symp-
toms of gastroesophageal reflux are controlled by
medications that suppress gastric acid.51,52
The restoration of normal squamous epithelium in
patients with Barrett’s esophagus has been a goal of
treatment that, until recently, has been unattainable.
The long-term suppression of acid, with or without
surgical fundoplication, does not reverse Barrett’s
esophagus.53,54 The application of new endoscopic
therapies aimed at the destruction of the metaplastic
columnar epithelium in the esophagus, followed by
squamous reepithelialization of the esophageal sur-
face during intensive suppression of acid by therapy
with proton-pump inhibitors, has been found to re-
verse Barrett’s esophagus (Fig. 4). Endoscopic ther-
mal methods that have been shown to have at least B
limited success in this regard include electrocoagula-
tion,55 argon plasma coagulation,56,57 laser therapy,58 Figure 4. Barrett’s Esophagus.
a combination of laser therapy and antireflux surgery,59 Panel A shows an endoscopic image of Barrett’s esophagus.
and photodynamic therapy.60-62 The thermal ablation Note the characteristic salmon-red color of the mucosa (arrow).
Panel B is an endoscopic image of the same patient after treat-
of metaplastic esophageal mucosa may be complicat- ment with endoscopic laser therapy and high-dose proton-pump
ed by the formation of an esophageal stricture, which inhibition. Note the squamous reepithelialization (the replace-
results in dysphagia. Of potentially greater concern ment of Barrett’s mucosa by pearly white squamous mucosa;
is that a substantial number of patients treated with arrow).
endoscopic thermal ablation have subsequently been
found to harbor foci of persistent columnar epithe-
lium beneath the reepithelialized squamous epithe-
lium. The important question of whether the risk of Achalasia
transformation to adenocarcinoma is eliminated by One of the most fascinating therapeutic innova-
endoscopic thermal ablation remains unanswered.63-65 tions in the treatment of patients with achalasia has
As yet, there are no reliably effective endoscopic, med- been the intrasphincteric injection of botulinum toxin
ical, or surgical therapies for patients with Barrett’s during endoscopy.66 Since the initial report, the rel-
esophagus, and thus no definitive recommendations atively short duration of the therapeutic response has
can be made regarding optimal treatment. been recognized.67-70 Approximately 40 to 50 per-

1742 · Decem b er 2 , 19 9 9
 MED ICA L PROGR ES S

cent of the patients treated with an intrasphincteric mucosa-associated lymphoid tissue (MALT) type or
injection of botulinum toxin require retreatment with- nodal non-Hodgkin’s lymphoma; the two forms may
in 12 months because of recurrent symptoms. When be differentiated by endoscopic and clinicopatho-
it is evaluated for a period of up to two years, re- logical features.83 Endoscopic ultrasonography is the
treatment with botulinum toxin is as effective as a method of choice for determining the stage of gas-
single pneumatic dilation. However, in selected pa- tric lymphoma and may be predictive of the response
tients with serious underlying medical disorders who to medical therapy.84,85 Endoscopic ultrasonography
would not be able to tolerate a dilation-induced esoph- is also the single best method to monitor the response
ageal perforation or the complications of surgical (or lack of response) to medical treatment.84,86,87
esophagomyotomy, a series of injections of botuli- Gastric cancer is associated with a five-year surviv-
num toxin may be preferable.71 al rate of approximately 15 percent and is one of the
most common solid tumors in the world.88 Early-stage
DIAGNOSIS AND STAGING gastric cancer is typically asymptomatic, and most
OF MALIGNANT DISEASE patients with gastric cancer have advanced disease at
Esophagus diagnosis. Although a number of precursors of gas-
Over the past decade, there have been striking ad- tric cancer have been identified, including gastric sur-
vances in endoscopy with regard to diagnosis, staging, gery, pernicious anemia, gastric adenoma, atrophic
and treatment of esophageal cancer. The diagnosis of gastritis, intestinal metaplasia, and Helicobacter py-
esophageal cancer is generally made by endoscopy in lori gastritis, no properly randomized trials have been
combination with biopsy or by barium-contrast ra- undertaken to demonstrate the value of endoscopic
diography followed by endoscopy and biopsy.72 Ear- monitoring of these conditions.89 Upper gastrointes-
ly-stage carcinomas of the esophagus are asymptomat- tinal endoscopy is considered the method of choice
ic, are usually detected incidentally during endoscopy for diagnosing gastric cancer, although the sensitiv-
performed for other indications, and are the most ity is only 81 percent.90 The role of computed tomog-
curable form of the disease. Because of their small raphy in determining the stage of gastric cancer is
size, such tumors may not be detected on contrast controversial because of its poor sensitivity in de-
radiography. Large esophageal carcinomas typically tecting perigastric spread and peritoneal dissemina-
present with dysphagia, are rarely curable, and rep- tion.91 Endoscopic ultrasonography is now well es-
resent the majority of cases diagnosed in the United tablished as the most sensitive and specific preoperative
States. method to determine the depth of penetration of
Therapy for patients with esophageal cancer is based gastric tumors (T stage) and to assess the local or re-
on the anatomical extent of the disease as assessed gional spread of the disease.92-95
with the TNM (tumor–node–metastasis) classifica- TREATMENT OF MALIGNANT DISEASE
tion system.73,74 Initial staging examinations should IN THE UPPER GASTROINTESTINAL TRACT
include computed tomographic scanning of the chest
and abdomen. If there is no evidence of metastatic Esophagus
disease, further staging (assessment of the T and At the time of diagnosis, 50 to 60 percent of esoph-
N classification) is performed through endoscopic ageal tumors are surgically unresectable. The overall
ultrasonography. prognosis, even after resection with curative intent,
Endoscopic ultrasonography has become essential is poor, with a long-term survival rate of less than 10
in the evaluation of esophageal cancer. It has been percent. Therefore, palliative care is critical in treat-
shown to be more accurate in determining the stage ing patients with esophageal cancer and cancers that
of esophageal tumors than is computed tomogra- metastasize to the esophagus. There are a variety of
phy75,76; to guide the selection of treatment for pa- endoscopic methods currently in use for palliation
tients with esophageal cancer77,78; to guide fine-needle of malignant dysphagia associated with esophageal
aspiration for the cytologic determination of malig- cancer. Endoscopic placement of a guide wire can fa-
nant lymph-node involvement (N classification)79; and cilitate fluoroscopically monitored bougienage with
to help detect recurrent esophageal cancer even in the polyvinyl dilators. Alternatively, dilation of a malig-
absence of endoscopically detectable disease (i.e., in nant esophageal stricture can be accomplished with
biopsy-negative disease).80,81 Endoscopic ultrasonog- a pneumatic dilator (an expandable balloon). Both
raphy is well established in clinical practice, and its ac- methods achieve adequate but often only temporary
curacy in tumor staging (T and N) is unsurpassed.75,82 relief and are not without risk.96 Endoscopically di-
rected thermal therapies that reduce the size of the
Stomach tumor include monopolar and bipolar electrocau-
The digestive tract is the most commonly involved tery and laser therapy (e.g., with a Nd:YAG or po-
extranodal site of non-Hodgkin’s lymphoma. Lym- tassium titanyl phosphate laser) (Fig. 5).
phomatous involvement of the stomach may be pres- The newest form of endoscopic thermal therapy is
ent as either primary gastric B-cell lymphoma of the argon plasma coagulation. Argon plasma coagulation

Vol ume 341 Numb e r 23 · 1743

 The New Eng land Jour nal of Medicine

is an electrosurgical technique in which electrical en-

ergy is transferred to the tissue by means of ionized,
electrically conductive argon gas. The equipment is
less expensive to purchase and operate than standard
laser equipment. Argon plasma coagulation also has
additional advantages over standard laser therapy, in-
cluding its capacity to perform therapy tangentially
(it does not have to be aimed directly at the lesion)
and its enhanced control over the extent to which
tissue is treated. Such advantages have made argon
plasma coagulation attractive for the treatment of ear-
ly-stage esophageal cancers as well as Barrett’s esoph-
agus and dysplasia.57
Photodynamic therapy is a nonthermal endoscop-
ic and laser-associated palliative technique approved
by the Food and Drug Administration for the treat-
A
ment of patients with esophageal cancer or lung can-
cer. Patients referred for photodynamic therapy must
be carefully selected because of the risk of skin pho-
tosensitivity (and subsequent skin damage), and treat-
ed patients must temporarily avoid direct exposure
to sunlight. After a specified interval following the
administration of a photosensitizer (a pharmaceuti-
cal agent that is retained selectively by neoplastic tis-
sue and activated by laser light), patients undergo
endoscopy, at which time light from a laser is direct-
ed onto the tumor containing the photosensitizer.
Once activated by laser light, the photosensitizer un-
dergoes a chemical reaction in which cytotoxic oxy-
gen radicals are formed. Tissue destruction is thus
limited to the tumor.
The results of a multicenter comparative trial sug-
gest that photodynamic therapy provides palliation
equivalent to that of Nd:YAG laser therapy and may B
be easier to perform.97 Because of its limited depth
Figure 5. Endoscopic Laser Therapy.
of effect, photodynamic therapy is currently approved
Panel A shows the endoscopic appearance of the gastroesoph-
only for palliation of malignant dysphagia. However, ageal junction in a patient with an adenocarcinoma causing
preliminary studies suggest that photodynamic ther- near-total obstruction. The patient declined chemoradiation ther-
apy may be effective as a primary treatment for pa- apy and was not deemed a candidate for surgery, because of
tients with small esophageal carcinomas who are poor severe coexisting illness. In Panel B, the same area is shown af-
candidates for surgery.98 Current research involving ter endoscopic laser photoablation of the tumor. Luminal pa-
tency had been restored. A hiatal hernia can be seen beyond
photosensitizers with more favorable safety profiles the treated tumor.
(e.g., a shorter duration of skin photosensitivity) has
shown promising results.61,99
Endoprostheses that are placed with an endoscope
can relieve dysphagia and close tracheoesophageal of perforation of approximately 14 percent as well as
fistulas. Such fistulas occur in 5 to 15 percent of pa- aspiration pneumonia and migration of the stent in
tients with esophageal cancer or metastatic mediasti- an additional 29 percent in a large prospective trial.101
nal disease.100 Such patients are usually unable to swal- Recently, a new type of stent has been developed
low any food or liquids without risking aspiration or that is associated with substantially reduced rates
food impaction; pneumonia, pyopneumothorax, and of complications.102-105 These self-expanding metallic
progressive pulmonary sepsis often develop. Attempts stents can be compressed into a narrow device that
to close or divert tracheoesophageal fistulas surgical- allows placement with minimal or no prior esopha-
ly have resulted in unacceptably high mortality rates. geal dilation. After insertion into the esophagus, the
Traditional rigid (plastic) esophageal stents can be delivery device is released and the stent expands rap-
placed across fistulas but require extensive dilation of idly to create an open lumen through which food
the tumor before placement to allow passage of the can pass. Self-expanding metallic stents can be used
large-diameter stents. This dilation resulted in rates to palliate intrinsic or extrinsic malignant obstruc-

1744 · Decem b er 2 , 19 9 9
 MED IC A L PROGR ES S

frequency electrocautery, either with or without band

ligation of the lesion. Endoscopic mucosal resection
is suitable for the treatment of benign gastric tumors
and early-stage gastric carcinomas smaller than 2 cm
in diameter.114,115
In the future, the treatment of patients with gas-
tric cancer may include the endoscopic injection of
chemotherapeutic agents. The successful response to
the injection of cisplatin with epinephrine into tu-
mors of the head and neck116 has stimulated the en-
doscopic application of such therapies in patients
with gastric cancer.117 Direct endoscopic or endoscop-
ic ultrasound-guided injection of new tumor-specific
treatments may improve the success of treatment of
a variety of gastrointestinal tumors.
Historically, gastric-outlet obstruction due to gas-
Figure 6. Endoscopic Palliation of Malignant Dysphagia.
tric or pancreatic cancer has been treated with sur-
Shown is an endoscopic view after the deployment of a self-
gical bypass. Because patients with gastric-outlet ob-
expanding metallic stent in a patient with malignant dysphagia struction present late in the course of their disease,
due to esophageal cancer. they are often only marginally suitable for even lim-
ited surgical intervention. In addition, patients who
have previously undergone gastric bypass operations
may present with recurrent obstruction due to pro-
tion of the esophagus (Fig. 6).106,107 Self-expanding gression of malignant disease. Just as expandable me-
metallic stents designed with a plastic polymer mem- tallic endoprostheses are now commonly used for the
brane or silicone covering can also seal fistulas effec- treatment of malignant esophageal obstruction, re-
tively.103,108-110 cent experience with similarly designed endopros-
Prospective randomized trials, including one in theses suggests that in the near future, expandable
which plastic stents were compared with self-expand- metallic stents may provide an endoscopic (and there-
ing metallic stents, have shown that self-expanding fore minimally invasive) alternative to surgical inter-
metallic stents are associated with a significantly low- vention in the small intestine.118-122
er rate of immediate complications and a reduced
length of hospital stay.111 A comparative trial that in-
volved patients without tracheoesophageal fistulas We are indebted to Dr. Lawrence S. Friedman for his critical re-
suggests that endoscopic laser therapy has a lower view of the manuscript.
rate of complications than either plastic stents or
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