ObjectivesThe aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ... more ObjectivesThe aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.
The value of narrow-band imaging (NBI) for detecting serrated lesions is unknown. To assess NBI f... more The value of narrow-band imaging (NBI) for detecting serrated lesions is unknown. To assess NBI for the detection of proximal colon serrated lesions. Randomized, controlled trial. Two academic hospital outpatient units. Eight hundred outpatients 50 years of age and older with intact colons undergoing routine screening, surveillance, or diagnostic examinations. Randomization to colon inspection in NBI versus white-light colonoscopy. The number of serrated lesions (sessile serrated polyps plus hyperplastic polyps) proximal to the sigmoid colon. The mean inspection times for the whole colon and proximal colon were the same for the NBI and white-light groups. There were 204 proximal colon lesions in the NBI group and 158 in the white light group (P = .085). Detection of conventional adenomas was comparable in the 2 groups. Lack of blinding, endoscopic estimation of polyp location. NBI may increase the detection of proximal colon serrated lesions, but the result in this trial did not rea...
Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endosco... more Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown.
Background/Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy ... more Background/Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy (TCB) are sensitive techniques for diagnosing mediastinal lesions, but it is unclear how either one or both should be used to obtain a pathologic diagnosis. The objective of our study was to evaluate whether EUS-TCB impacts the diagnosis of mediastinal lesions after the initial on-site review of EUS-FNA specimen suggests a suboptimal result. Methods: We enrolled consecutive patients with mediastinal lesions who underwent EUS-TCB during the same procedure if the initial EUS-FNA demonstrated an inadequate FNA sample or suggested that histopathology was required for diagnosis. Diagnostic accuracies between procedures were compared as the main outcome. Results: Twenty-seven patients (14 men; median age, 56 years; range, 19 to 82 years) underwent EUS-FNA and EUS-TCB to evaluate a mediastinal lymphadenopathy or mass (n=17), to determine the cancer stage (n=3) or to exclude tumor recurrence or metastasis (n=7). The overall diagnostic accuracies of EUS-FNA and EUS-TCB were 78% and 67%, respectively (p=0.375). The combined diagnostic accuracy of EUS-FNA plus EUS-TCB was 82%. In six patients with nondiagnostic EUS-FNA, EUS-TCB provided a final diagnosis in one patient (17%). Conclusions: In the current series of patients with mediastinal masses or adenopathy, the administration of EUS-TCB following suboptimal results for the onsite cytology review did not increase the diagnostic yield.
Background-The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Ob... more Background-The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Objectives-To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. Design-Retrospective cohort study. Setting-Tertiary-care referral center. Patients-All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. Intervention-EUS. Main Outcome Measurements-Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiveroperating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. Results-We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/ specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97
Background. The aim of this study was to evaluate the role and impact of EUS in the management of... more Background. The aim of this study was to evaluate the role and impact of EUS in the management of critically ill patients. Methods. We retrospectively identified all patients at our institution over a 68-month period in whom bedside inpatient EUS was performed. EUS was considered to have a significant impact if a new diagnosis was established and/or the findings altered subsequent clinical management. Results. Fifteen patients (9 male; mean age years) underwent bedside EUS without complications. EUS-FNA (median 4 passes; range 2–7) performed in 12 (80%) demonstrated a malignant mediastinal mass/lymph node (5), pancreatic abscess (1), excluded a pelvic abscess (1), established enlarged gastric folds as benign (1) and excluded malignancy in enlarged mediastinal (1) and porta hepatis adenopathy (1). In two patients, EUS-FNA failed to diagnose mediastinal histoplasmosis (1) and a hemorrhagic pancreatic pseudocyst (1). In three diagnostic exams without FNA, EUS correctly excluded choledo...
ABSTRACT The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy ... more ABSTRACT The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown. To assess the incremental yield of EUS after endoscopic polypectomy of a high-risk rectal lesion. Retrospective cohort. Tertiary referral center. Patients referred for EUS following attempted endoscopic resection of a high-risk rectal neoplasm, defined as a tubulovillous adenoma, tubular adenoma with high-grade dysplasia, carcinoid, carcinoma in-situ or adenocarcinoma (CA). Sigmoidoscopy ± mucosal biopsy and EUS ± fine-needle aspiration (FNA) to evaluate for: (1) Residual polyp/tumor in the rectal wall or (2) peritumoral adenopathy. Sensitivity and specificity for detection of residual neoplasia for WLE ± biopsy (WLE/BX) and EUS ± FNA for cancer (CA group) or benign disease (non-CA group). The incremental yield of EUS defined as: (1) Residual intramural neoplasia not present on WLE ± BX and; (2) abnormal peritumoral adenopathy. A total of 70 patients (mean age 64 ± 11 years, 61% male) with a final diagnosis of CA (n = 38) and non-CA (n = 32) were identified. There was no difference between the sensitivity and specificity of WLE alone (65% and 84%), WLE with biopsy (71% and 95%), and EUS (59% and 84%), for the detection of residual neoplasia (P > 0.05 for all). EUS identified 3 masses missed by WLE, all in the CA group. A malignant (n = 2) or benign (n = 3) node was identified in 5 (13%) CA patients; EUS-FNA in two showed residual malignancy in one and a reactive lymph node (LN) in one. No LNs were identified in the non-CA patients. Retrospective design, incomplete follow-up in some patients. Following endoscopic polypectomy of high-risk rectal neoplasia, the incremental yield of EUS compared with WLE/BX for evaluation of residual disease appears limited, especially in patients with benign disease.
Introduction: Pancreatic neuroendocrine tumors (NETs) are rare neoplasms that are classified as f... more Introduction: Pancreatic neuroendocrine tumors (NETs) are rare neoplasms that are classified as functional (F-NET) or nonfunctional (NF-NET) depending on the presence or absence of excess hormone production. Endoscopic ultrasound ...
Introduction: Pancreatic neuroendocrine tumors (NET) are rare neoplasms that are classified as fu... more Introduction: Pancreatic neuroendocrine tumors (NET) are rare neoplasms that are classified as functional (F-NET) or nonfunctional (NF-NET) depending on the presence or absence of excess hormone production. Endoscopic ultrasound ...
Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasi... more Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. Methods: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. Results: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CTguided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. Conclusions: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended. (Gastrointest Endosc 2003;58:542-8.) EUS-FNA of recurrent postoperative extraluminal or metastatic malignancy
Background and Aim: Previous studies that addressed the outcome of balloon-assisted enteroscopy (... more Background and Aim: Previous studies that addressed the outcome of balloon-assisted enteroscopy (BAE) were based on its early experience. The accumulated BAE experience over the last decade might affect its pattern of use and outcome. In order to evaluate the changes of BAE practice over time, we compared the indications, diagnostic yield, and complication rate between the early and late stages of BAE implementation. Methods: This multicenter study analyzed BAE-related factors of 1108 BAE procedures carried out in 860 patients and compared BAE done at an earlier stage (January 2004-August 2008) to those carried out at a later stage (September 2008-February 2013). Results: The most common indication for BAE was obscure gastrointestinal bleeding (58.3%). In the early stage, BAE to assess unexplained symptoms/signs was more common (18.8% vs 9.7%), whereas BAE to confirm abnormal findings of imaging studies was more common in the late stage (9.4% vs 18.8%, P < 0.001). Overall diagnostic yield of BAE was 74.6% (95% CI, 72.0-77.1%). There was no significant difference in the diagnostic yield between the early and late stages (72.2% vs 77.0%, P = 0.073). BAEassociated complications occurred in 12 procedures (1.1%; 95% CI, 0.6-1.9%). The complication rate decreased significantly in the late stage compared to that during in the early stage (1.8% vs 0.4%, P = 0.020). Conclusion: BAE is a safe and useful tool for the diagnosis and management of small bowel disease. With time, the indications for BAE have become more specific and the BAE-associated complication rate has decreased.
Introduction Several quality indicators have been suggested to monitor the quality of colonoscopy... more Introduction Several quality indicators have been suggested to monitor the quality of colonoscopy. It has been shown that one of these quality indicators, the adenoma detection rate (ADR) was negatively associated with the occurrence of interval cancers in a colorectal cancer (CRC) screening program. Endoscopists with ADR below 20% had a higher risk of interval colorectal cancer. This study aimed to determine whether the ADR also differs between different endoscopy units and to assess underlying factors. Methods From 12 endoscopy units from the Netherlands 400 consecutive colonoscopy and pathology reports were obtained. Data consisted of demographics, indication, findings, and polyp descriptors like size, location, and histology. Analyses were restricted to patients without IBD or an intervention as indication for the procedure. Endoscopy units were divided in 2 categories based on an ADR threshold of 20%. Results During 4,238 colonoscopies (male gender: 47%, mean age: 60 years) adenomas were detected in 1,111 procedures (ADR: 26%): these were proximal in 7%, distal in 8%, both distal and proximal in 3%, and location was not specified in 8%. Advanced neoplasia was found in 670 procedures (16% of all procedures): high grade dysplasia (HGD) in 7% (nϭ281), size Ն10 mm in 7% (294), villous component in 7% (267), Ն3 adenomas in 4% (184) and CRC 5% (214). Adenoma bearing patients were more often male (32 vs. 21%, pϽ0.01) and older (mean age: 67 vs. 58 years, pϽ0.01).The ADR differed between units, ranging from 14 to 33% (pϽ0.01). Three units had an ADR Ͻ20%. No differences were found in patients' age (pϭ0.08) and gender (pϭ0.63) between units with an ADR Ͻ20% and Ͼ20%. In units with an ADR Ͻ20%, endoscopists were more experienced (mean colonoscopy experience: 18 vs. 13 years, pϽ0.01) and procedures were more often performed by internists (28 vs. 4%, pϽ0.01), surgeons (3 vs. 0.3%, pϽ0.01), but no fellows or nurse-endoscopists were involved, in contrast to the units with an ADR Ͼ20% (20 and 5%). Units with an ADR Ͻ20% had more patients with symptoms (72 vs. 63%, pϽ0.01).Lower cecal intubation rates were observed in units with ADR Ͻ20% (87 vs. 93%, pϽ0.01), and sedatives were used less often (79 vs. 92%, pϽ0.01). Findings between the units with an ADR Ͻ20% and Ͼ20% differed in number (Ͼ2 adenomas in a procedure: 1 vs. 5%, pϽ0.01), and location of adenomas (any proximal adenoma: 5 vs. 13%, pϽ0.01), but not in adenoma size (any adenoma Ն10 mm: 7 vs. 7%, pϭ0.52).Table 1 shows factors associated with the detection of an adenoma. Conclusion There are major differences in average ADR between different endoscopy units. Both patient-related factors and endoscopist-related factors influence the ADR. Continuous quality assurance on endoscopy departments should be undertaken to detect reasons for differences to improve overall quality of colonoscopy performance.
Endoscopic therapy for pancreas divisum requires cannulation of the minor papilla, and, with suff... more Endoscopic therapy for pancreas divisum requires cannulation of the minor papilla, and, with sufficient expertise, access may be achieved in greater than 90% of patients. 1,2 When dorsal duct cannulation is difficult, various methods, including intravenous administration of secretin 3 and direct application of dilute methylene blue (MB) to the surface of the minor papilla 4 have been described. In rare cases, however, cannulation may be unsuccessful for a
EUS-Guided Paracentesis: Experience in 60 Consecutive Patients John Dewitt, Stuart Sherman, Lee M... more EUS-Guided Paracentesis: Experience in 60 Consecutive Patients John Dewitt, Stuart Sherman, Lee Mchenry, Kathy Mcgreevy, Julia Leblanc Background: The utility and safety of EUS-FNA sampling ascitic fluid is poorly defined. Methods: Databases were queried for all patients with successful EUSguided paracentesis from 1997 to 2005 at our hospital. Procedure reports and hospital charts were reviewed to confirm the cytologic diagnosis and clinical follow up. Results: 60 consecutive patients (33 male; mean age: 67 yrs) underwent EUSguided paracentesis. The most common indications for EUS were a known/ suspected pancreatic mass or cyst (31) or abnormal ERCP (10). Previously attempted percutaneous paracentesis was unsucessful in 3/6 patients due to inability to localize fluid for aspiration. Ascites seen by EUS was visible in only 28/54 (52%), 3/11 (27%) and 4/8 (50%) CT, US and MRI exams, respectively before EUS. Transgastric (55) or transduodenal (5) EUS-guided paracentesis (mean: 8.9 mLs; range: 1-40) revealed malignancy in 16 (27%) from primary pancreatic (9), gastric (2), urothelial (1), esophageal (1), gallbladder (1), bile duct (1) cancer or lymphoma (1). Cytology from one was suspicious for malignancy and the remaining 43 were benign. Seven with negative (6) or malignant (1) cytology from EUS-FNA underwent surgery a mean 26 days after EUS. The one with malignant ascites by EUS-FNA was confirmed intraoperatively the next day by biopsy of a peritoneal nodule. Two of the remaining six managed surgically were found to have metastatic carcinoid (1) or pancreatic adenocarcinoma (1) to the peritoneum following negative EUS-FNA cytology. Potential complications occurred in 3/60 (5%), each of whom received post-procedure antibiotics. One developed a fever 2 days after EUS, was hospitalized and discharged with negative cultures after three days. One had a fever and was treated as an outpatient for a suspected UTI. The third was asymptomatic but had air in the pancreas found on staging CT one day after EUS. This patient was managed medically and discharged with negative cultures. 45/60 (75%) received IV and/or oral antibiotics following EUS-FNA. Twelve of 16 with malignant ascites diagnosed by EUS-FNA died a mean 77 days (range: 21-167) after EUS. Four with metastatic esophageal (1), pancreatic (1) or gastric (1) cancer and lymphoma (1) remain alive 30, 110, 640 and 913 days after EUS. Conclusions: In this largest series to date, EUS frequently visualized ascites missed by other imaging studies. EUS-guided paracentesis is relatively safe, demonstrates malignancy in 27% of patients but a negative cytology does not exclude malignancy. Prognosis following detection of malignant ascites is usually poor. EUS-FNA of ascites should be performed in all patients with suspected or confirmed malignancy.
Background: The diagnosis of early chronic pancreatitis (CP) is difficult and the role of EUS-FNA... more Background: The diagnosis of early chronic pancreatitis (CP) is difficult and the role of EUS-FNA cytology remains debatable. Aims: 1) determine the utility and safety profile of EUS-guided tru-cut biopsy (EUS-TCB; Quick-Core, Wilson-Cook Medical, Inc.) for the diagnosis of suspected nonfocal CP; 2) Compare agreement of EUS and ERCP to each other and individually to EUS-TCB for suspected CP. Methods: Inclusion criteria: Patients between 18-60 yrs old with O 3 months of upper abdominal pain and suspected CP. Exclusion criteria: Prior pancreatic or upper GI tract surgery, thrombocytopenia, anemia, coagulopathy, CAD, pancreatic cancer or cyst, or acute pancreatitis or pancreatic stent within the previous 3 months. Patients with 3 or more EUS criteria for CP within the body and neck on radial EUS underwent attempted transgastric EUS-TCB followed within one week by ERCP. The endoscopist performing ERCP was blinded to the EUS results. All pathology was examined by one expert pathologist. The severity of CP was stratified by Cambridge classification for ERCP and by the number of ductal/parenchymal criteria present at EUS (normal: 0; equivocal: 1-2, mild: 3-4; moderate: 5-6; severe O 6). Agreement between tests was evaluated by a kappa statistic. Results: Of 45 patients screened, 30 were enrolled (12 male, 39 white; mean age: 44), all of whom underwent EUS. Of these, 18 had 3 or more EUS criteria and 16 underwent attempted EUS-TCB. Two with calcific pancreatitis could not be safely biopsied. EUS-TCB results: normal pancreas (8; mean tissue length: 5.8 G 3.4 mm; range: 0-13 mm), nondiagnostic (6), device malfunction (1), and chronic pancreatitis (1; length: 6 mm). EUS-TCB complications: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were discharged within 23 hrs. 8 declined ERCP following EUS; 22 underwent ERCP. Complications after ERCP: mild acute pancreatitis (1) and minor post-sphincterotomy bleeding. Of the 8 with normal pancreatic histology, ERCP was not done (1), normal (4) or showed mild (2) or moderate CP (1). Agreement between diagnostic EUS and ERCP: fair (kappa: 0.40); between diagnostic EUS and ERCP with EUS-TCB was poor (kappa: 0) and fair (kappa: 0.25), respectively. Conclusion: EUS-TCB was relatively safe but did not routinely demonstrate histologic CP with suspected disease. The role of EUS-TCB for the diagnosis of CP remains to be defined.
The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology f... more The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology for this indication remains unclear. The aim of this study is to determine the utility and the safety profile of EUS-guided Trucut biopsy (EUS-TCB) for the histologic diagnosis of suspected nonfocal CP. After radial EUS, patients with suspected CP (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =3 EUS criteria) underwent attempted transgastric EUS-TCB of the pancreas. Histopathologic specimens were examined by one pathologist and were classified as nondiagnostic, normal pancreas, and probable or definite CP. Within 1 week after EUS, ERCP was performed by an endoscopist blinded to the EUS results. The severity of CP by ERCP was stratified by the Cambridge classification. Agreement between tests for the diagnosis of CP was evaluated by a kappa statistic. Of 45 patients screened, 15 declined and 30 (12 men and 18 women, mean age 44 years) underwent diagnostic EUS. Of these, 18 (60%) had suspected CP and 16 underwent attempted biopsy. Calcific pancreatitis in two patients precluded EUS-TCB. EUS-TCB results were as follows: probable CP (1), normal pancreas (8), nondiagnostic (6), device malfunction (1). Complications after EUS-TCB occurred in two patients with normal pancreatic biopsies were the following: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were hospitalized and discharged within 23 hours. Six patients refused ERCP and two (per protocol) did not undergo ERCP. For the remaining 22, agreement between diagnostic EUS and ERCP was moderate (kappa, 0.40). Agreement between EUS and ERCP with EUS-TCB were poor (kappa, 0) and fair (kappa, 0.25), respectively. Transgastric EUS-TCB of suspected nonfocal CP infrequently demonstrates histologic CP in clinically suspected disease. Because of potential complications and limited diagnostic yield, this technique is not currently recommended for evaluation of these patients.
Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tis... more Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route. To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease. A prospective case series. A tertiary-referral hospital in Indianapolis, Indiana. Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease. EUS-TCB of the liver. Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts. Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications. The small sample size and low-risk population. In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.
ObjectivesThe aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ... more ObjectivesThe aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.
The value of narrow-band imaging (NBI) for detecting serrated lesions is unknown. To assess NBI f... more The value of narrow-band imaging (NBI) for detecting serrated lesions is unknown. To assess NBI for the detection of proximal colon serrated lesions. Randomized, controlled trial. Two academic hospital outpatient units. Eight hundred outpatients 50 years of age and older with intact colons undergoing routine screening, surveillance, or diagnostic examinations. Randomization to colon inspection in NBI versus white-light colonoscopy. The number of serrated lesions (sessile serrated polyps plus hyperplastic polyps) proximal to the sigmoid colon. The mean inspection times for the whole colon and proximal colon were the same for the NBI and white-light groups. There were 204 proximal colon lesions in the NBI group and 158 in the white light group (P = .085). Detection of conventional adenomas was comparable in the 2 groups. Lack of blinding, endoscopic estimation of polyp location. NBI may increase the detection of proximal colon serrated lesions, but the result in this trial did not rea...
Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endosco... more Background: The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown.
Background/Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy ... more Background/Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and Trucut biopsy (TCB) are sensitive techniques for diagnosing mediastinal lesions, but it is unclear how either one or both should be used to obtain a pathologic diagnosis. The objective of our study was to evaluate whether EUS-TCB impacts the diagnosis of mediastinal lesions after the initial on-site review of EUS-FNA specimen suggests a suboptimal result. Methods: We enrolled consecutive patients with mediastinal lesions who underwent EUS-TCB during the same procedure if the initial EUS-FNA demonstrated an inadequate FNA sample or suggested that histopathology was required for diagnosis. Diagnostic accuracies between procedures were compared as the main outcome. Results: Twenty-seven patients (14 men; median age, 56 years; range, 19 to 82 years) underwent EUS-FNA and EUS-TCB to evaluate a mediastinal lymphadenopathy or mass (n=17), to determine the cancer stage (n=3) or to exclude tumor recurrence or metastasis (n=7). The overall diagnostic accuracies of EUS-FNA and EUS-TCB were 78% and 67%, respectively (p=0.375). The combined diagnostic accuracy of EUS-FNA plus EUS-TCB was 82%. In six patients with nondiagnostic EUS-FNA, EUS-TCB provided a final diagnosis in one patient (17%). Conclusions: In the current series of patients with mediastinal masses or adenopathy, the administration of EUS-TCB following suboptimal results for the onsite cytology review did not increase the diagnostic yield.
Background-The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Ob... more Background-The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Objectives-To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. Design-Retrospective cohort study. Setting-Tertiary-care referral center. Patients-All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. Intervention-EUS. Main Outcome Measurements-Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiveroperating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. Results-We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/ specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97
Background. The aim of this study was to evaluate the role and impact of EUS in the management of... more Background. The aim of this study was to evaluate the role and impact of EUS in the management of critically ill patients. Methods. We retrospectively identified all patients at our institution over a 68-month period in whom bedside inpatient EUS was performed. EUS was considered to have a significant impact if a new diagnosis was established and/or the findings altered subsequent clinical management. Results. Fifteen patients (9 male; mean age years) underwent bedside EUS without complications. EUS-FNA (median 4 passes; range 2–7) performed in 12 (80%) demonstrated a malignant mediastinal mass/lymph node (5), pancreatic abscess (1), excluded a pelvic abscess (1), established enlarged gastric folds as benign (1) and excluded malignancy in enlarged mediastinal (1) and porta hepatis adenopathy (1). In two patients, EUS-FNA failed to diagnose mediastinal histoplasmosis (1) and a hemorrhagic pancreatic pseudocyst (1). In three diagnostic exams without FNA, EUS correctly excluded choledo...
ABSTRACT The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy ... more ABSTRACT The utility of endoscopic ultrasound (EUS) compared with standard white light endoscopy (WLE) following recent polypectomy of high-risk colorectal polyps is unknown. To assess the incremental yield of EUS after endoscopic polypectomy of a high-risk rectal lesion. Retrospective cohort. Tertiary referral center. Patients referred for EUS following attempted endoscopic resection of a high-risk rectal neoplasm, defined as a tubulovillous adenoma, tubular adenoma with high-grade dysplasia, carcinoid, carcinoma in-situ or adenocarcinoma (CA). Sigmoidoscopy ± mucosal biopsy and EUS ± fine-needle aspiration (FNA) to evaluate for: (1) Residual polyp/tumor in the rectal wall or (2) peritumoral adenopathy. Sensitivity and specificity for detection of residual neoplasia for WLE ± biopsy (WLE/BX) and EUS ± FNA for cancer (CA group) or benign disease (non-CA group). The incremental yield of EUS defined as: (1) Residual intramural neoplasia not present on WLE ± BX and; (2) abnormal peritumoral adenopathy. A total of 70 patients (mean age 64 ± 11 years, 61% male) with a final diagnosis of CA (n = 38) and non-CA (n = 32) were identified. There was no difference between the sensitivity and specificity of WLE alone (65% and 84%), WLE with biopsy (71% and 95%), and EUS (59% and 84%), for the detection of residual neoplasia (P &gt; 0.05 for all). EUS identified 3 masses missed by WLE, all in the CA group. A malignant (n = 2) or benign (n = 3) node was identified in 5 (13%) CA patients; EUS-FNA in two showed residual malignancy in one and a reactive lymph node (LN) in one. No LNs were identified in the non-CA patients. Retrospective design, incomplete follow-up in some patients. Following endoscopic polypectomy of high-risk rectal neoplasia, the incremental yield of EUS compared with WLE/BX for evaluation of residual disease appears limited, especially in patients with benign disease.
Introduction: Pancreatic neuroendocrine tumors (NETs) are rare neoplasms that are classified as f... more Introduction: Pancreatic neuroendocrine tumors (NETs) are rare neoplasms that are classified as functional (F-NET) or nonfunctional (NF-NET) depending on the presence or absence of excess hormone production. Endoscopic ultrasound ...
Introduction: Pancreatic neuroendocrine tumors (NET) are rare neoplasms that are classified as fu... more Introduction: Pancreatic neuroendocrine tumors (NET) are rare neoplasms that are classified as functional (F-NET) or nonfunctional (NF-NET) depending on the presence or absence of excess hormone production. Endoscopic ultrasound ...
Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasi... more Background: EUS-guided FNA is safe and accurate for the diagnosis of benign or malignant neoplasia and lymphadenopathy; however, its role in the diagnosis of recurrent malignancy is not well described. Methods: A prospectively updated EUS-guided FNA cytology database was used to identify patients in whom a diagnosis of postoperative, recurrent, extraluminal, or metastatic malignancy was made over a 5-year period. Only patients with a positive EUS-guided FNA were included in the analysis. All had undergone surgery for the primary malignancy and were in clinical and/or radiographic remission before the initial suspicion of tumor recurrence. Results: Twenty-one patients underwent EUS-guided FNA of 21 lesions (19 masses, 2 lymph nodes) because of a suspicion of recurrent malignancy based on CT (n = 17) or EUS (n = 4) findings. Median time from the initial diagnosis to recurrence was 26 months (range 5-276 months). Lesions were located in the pancreas (9 patients), mediastinum (7), liver (3), perigastric region (1), and liver hilum (1). EUS-guided FNA (mean number of needle passes, 4.5; range 2-8) obtained diagnostic material for recurrent malignancy in all patients as follows: esophageal (6 patients), renal cell (6), pancreatic (2), breast (2), colon (2), bile duct (1), Ewing's sarcoma (1), and lung (1) cancer. No complication was encountered. Transgastric EUS-guided FNA (4 patients), distal, or transesophageal EUS-FNA (2) proximal to a surgical anastomosis was required to confirm recurrence in all 6 patients with esophageal cancer. The initial cytologic diagnosis of recurrent malignancy was made by EUS in 20 of 21 (95%) patients. One patient with recurrent breast cancer had CTguided FNA of a right lung mass preceding EUS-guided FNA of an AP window lymph node. Conclusions: EUS-guided FNA can detect and safely diagnose recurrent malignancy in the mediastinum, retroperitoneum, and liver. When possible, correlation between EUS-guided FNA cytology and original tumor histopathology/cytology, or the use of immunostaining to confirm the diagnosis, is recommended. (Gastrointest Endosc 2003;58:542-8.) EUS-FNA of recurrent postoperative extraluminal or metastatic malignancy
Background and Aim: Previous studies that addressed the outcome of balloon-assisted enteroscopy (... more Background and Aim: Previous studies that addressed the outcome of balloon-assisted enteroscopy (BAE) were based on its early experience. The accumulated BAE experience over the last decade might affect its pattern of use and outcome. In order to evaluate the changes of BAE practice over time, we compared the indications, diagnostic yield, and complication rate between the early and late stages of BAE implementation. Methods: This multicenter study analyzed BAE-related factors of 1108 BAE procedures carried out in 860 patients and compared BAE done at an earlier stage (January 2004-August 2008) to those carried out at a later stage (September 2008-February 2013). Results: The most common indication for BAE was obscure gastrointestinal bleeding (58.3%). In the early stage, BAE to assess unexplained symptoms/signs was more common (18.8% vs 9.7%), whereas BAE to confirm abnormal findings of imaging studies was more common in the late stage (9.4% vs 18.8%, P < 0.001). Overall diagnostic yield of BAE was 74.6% (95% CI, 72.0-77.1%). There was no significant difference in the diagnostic yield between the early and late stages (72.2% vs 77.0%, P = 0.073). BAEassociated complications occurred in 12 procedures (1.1%; 95% CI, 0.6-1.9%). The complication rate decreased significantly in the late stage compared to that during in the early stage (1.8% vs 0.4%, P = 0.020). Conclusion: BAE is a safe and useful tool for the diagnosis and management of small bowel disease. With time, the indications for BAE have become more specific and the BAE-associated complication rate has decreased.
Introduction Several quality indicators have been suggested to monitor the quality of colonoscopy... more Introduction Several quality indicators have been suggested to monitor the quality of colonoscopy. It has been shown that one of these quality indicators, the adenoma detection rate (ADR) was negatively associated with the occurrence of interval cancers in a colorectal cancer (CRC) screening program. Endoscopists with ADR below 20% had a higher risk of interval colorectal cancer. This study aimed to determine whether the ADR also differs between different endoscopy units and to assess underlying factors. Methods From 12 endoscopy units from the Netherlands 400 consecutive colonoscopy and pathology reports were obtained. Data consisted of demographics, indication, findings, and polyp descriptors like size, location, and histology. Analyses were restricted to patients without IBD or an intervention as indication for the procedure. Endoscopy units were divided in 2 categories based on an ADR threshold of 20%. Results During 4,238 colonoscopies (male gender: 47%, mean age: 60 years) adenomas were detected in 1,111 procedures (ADR: 26%): these were proximal in 7%, distal in 8%, both distal and proximal in 3%, and location was not specified in 8%. Advanced neoplasia was found in 670 procedures (16% of all procedures): high grade dysplasia (HGD) in 7% (nϭ281), size Ն10 mm in 7% (294), villous component in 7% (267), Ն3 adenomas in 4% (184) and CRC 5% (214). Adenoma bearing patients were more often male (32 vs. 21%, pϽ0.01) and older (mean age: 67 vs. 58 years, pϽ0.01).The ADR differed between units, ranging from 14 to 33% (pϽ0.01). Three units had an ADR Ͻ20%. No differences were found in patients' age (pϭ0.08) and gender (pϭ0.63) between units with an ADR Ͻ20% and Ͼ20%. In units with an ADR Ͻ20%, endoscopists were more experienced (mean colonoscopy experience: 18 vs. 13 years, pϽ0.01) and procedures were more often performed by internists (28 vs. 4%, pϽ0.01), surgeons (3 vs. 0.3%, pϽ0.01), but no fellows or nurse-endoscopists were involved, in contrast to the units with an ADR Ͼ20% (20 and 5%). Units with an ADR Ͻ20% had more patients with symptoms (72 vs. 63%, pϽ0.01).Lower cecal intubation rates were observed in units with ADR Ͻ20% (87 vs. 93%, pϽ0.01), and sedatives were used less often (79 vs. 92%, pϽ0.01). Findings between the units with an ADR Ͻ20% and Ͼ20% differed in number (Ͼ2 adenomas in a procedure: 1 vs. 5%, pϽ0.01), and location of adenomas (any proximal adenoma: 5 vs. 13%, pϽ0.01), but not in adenoma size (any adenoma Ն10 mm: 7 vs. 7%, pϭ0.52).Table 1 shows factors associated with the detection of an adenoma. Conclusion There are major differences in average ADR between different endoscopy units. Both patient-related factors and endoscopist-related factors influence the ADR. Continuous quality assurance on endoscopy departments should be undertaken to detect reasons for differences to improve overall quality of colonoscopy performance.
Endoscopic therapy for pancreas divisum requires cannulation of the minor papilla, and, with suff... more Endoscopic therapy for pancreas divisum requires cannulation of the minor papilla, and, with sufficient expertise, access may be achieved in greater than 90% of patients. 1,2 When dorsal duct cannulation is difficult, various methods, including intravenous administration of secretin 3 and direct application of dilute methylene blue (MB) to the surface of the minor papilla 4 have been described. In rare cases, however, cannulation may be unsuccessful for a
EUS-Guided Paracentesis: Experience in 60 Consecutive Patients John Dewitt, Stuart Sherman, Lee M... more EUS-Guided Paracentesis: Experience in 60 Consecutive Patients John Dewitt, Stuart Sherman, Lee Mchenry, Kathy Mcgreevy, Julia Leblanc Background: The utility and safety of EUS-FNA sampling ascitic fluid is poorly defined. Methods: Databases were queried for all patients with successful EUSguided paracentesis from 1997 to 2005 at our hospital. Procedure reports and hospital charts were reviewed to confirm the cytologic diagnosis and clinical follow up. Results: 60 consecutive patients (33 male; mean age: 67 yrs) underwent EUSguided paracentesis. The most common indications for EUS were a known/ suspected pancreatic mass or cyst (31) or abnormal ERCP (10). Previously attempted percutaneous paracentesis was unsucessful in 3/6 patients due to inability to localize fluid for aspiration. Ascites seen by EUS was visible in only 28/54 (52%), 3/11 (27%) and 4/8 (50%) CT, US and MRI exams, respectively before EUS. Transgastric (55) or transduodenal (5) EUS-guided paracentesis (mean: 8.9 mLs; range: 1-40) revealed malignancy in 16 (27%) from primary pancreatic (9), gastric (2), urothelial (1), esophageal (1), gallbladder (1), bile duct (1) cancer or lymphoma (1). Cytology from one was suspicious for malignancy and the remaining 43 were benign. Seven with negative (6) or malignant (1) cytology from EUS-FNA underwent surgery a mean 26 days after EUS. The one with malignant ascites by EUS-FNA was confirmed intraoperatively the next day by biopsy of a peritoneal nodule. Two of the remaining six managed surgically were found to have metastatic carcinoid (1) or pancreatic adenocarcinoma (1) to the peritoneum following negative EUS-FNA cytology. Potential complications occurred in 3/60 (5%), each of whom received post-procedure antibiotics. One developed a fever 2 days after EUS, was hospitalized and discharged with negative cultures after three days. One had a fever and was treated as an outpatient for a suspected UTI. The third was asymptomatic but had air in the pancreas found on staging CT one day after EUS. This patient was managed medically and discharged with negative cultures. 45/60 (75%) received IV and/or oral antibiotics following EUS-FNA. Twelve of 16 with malignant ascites diagnosed by EUS-FNA died a mean 77 days (range: 21-167) after EUS. Four with metastatic esophageal (1), pancreatic (1) or gastric (1) cancer and lymphoma (1) remain alive 30, 110, 640 and 913 days after EUS. Conclusions: In this largest series to date, EUS frequently visualized ascites missed by other imaging studies. EUS-guided paracentesis is relatively safe, demonstrates malignancy in 27% of patients but a negative cytology does not exclude malignancy. Prognosis following detection of malignant ascites is usually poor. EUS-FNA of ascites should be performed in all patients with suspected or confirmed malignancy.
Background: The diagnosis of early chronic pancreatitis (CP) is difficult and the role of EUS-FNA... more Background: The diagnosis of early chronic pancreatitis (CP) is difficult and the role of EUS-FNA cytology remains debatable. Aims: 1) determine the utility and safety profile of EUS-guided tru-cut biopsy (EUS-TCB; Quick-Core, Wilson-Cook Medical, Inc.) for the diagnosis of suspected nonfocal CP; 2) Compare agreement of EUS and ERCP to each other and individually to EUS-TCB for suspected CP. Methods: Inclusion criteria: Patients between 18-60 yrs old with O 3 months of upper abdominal pain and suspected CP. Exclusion criteria: Prior pancreatic or upper GI tract surgery, thrombocytopenia, anemia, coagulopathy, CAD, pancreatic cancer or cyst, or acute pancreatitis or pancreatic stent within the previous 3 months. Patients with 3 or more EUS criteria for CP within the body and neck on radial EUS underwent attempted transgastric EUS-TCB followed within one week by ERCP. The endoscopist performing ERCP was blinded to the EUS results. All pathology was examined by one expert pathologist. The severity of CP was stratified by Cambridge classification for ERCP and by the number of ductal/parenchymal criteria present at EUS (normal: 0; equivocal: 1-2, mild: 3-4; moderate: 5-6; severe O 6). Agreement between tests was evaluated by a kappa statistic. Results: Of 45 patients screened, 30 were enrolled (12 male, 39 white; mean age: 44), all of whom underwent EUS. Of these, 18 had 3 or more EUS criteria and 16 underwent attempted EUS-TCB. Two with calcific pancreatitis could not be safely biopsied. EUS-TCB results: normal pancreas (8; mean tissue length: 5.8 G 3.4 mm; range: 0-13 mm), nondiagnostic (6), device malfunction (1), and chronic pancreatitis (1; length: 6 mm). EUS-TCB complications: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were discharged within 23 hrs. 8 declined ERCP following EUS; 22 underwent ERCP. Complications after ERCP: mild acute pancreatitis (1) and minor post-sphincterotomy bleeding. Of the 8 with normal pancreatic histology, ERCP was not done (1), normal (4) or showed mild (2) or moderate CP (1). Agreement between diagnostic EUS and ERCP: fair (kappa: 0.40); between diagnostic EUS and ERCP with EUS-TCB was poor (kappa: 0) and fair (kappa: 0.25), respectively. Conclusion: EUS-TCB was relatively safe but did not routinely demonstrate histologic CP with suspected disease. The role of EUS-TCB for the diagnosis of CP remains to be defined.
The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology f... more The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology for this indication remains unclear. The aim of this study is to determine the utility and the safety profile of EUS-guided Trucut biopsy (EUS-TCB) for the histologic diagnosis of suspected nonfocal CP. After radial EUS, patients with suspected CP (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =3 EUS criteria) underwent attempted transgastric EUS-TCB of the pancreas. Histopathologic specimens were examined by one pathologist and were classified as nondiagnostic, normal pancreas, and probable or definite CP. Within 1 week after EUS, ERCP was performed by an endoscopist blinded to the EUS results. The severity of CP by ERCP was stratified by the Cambridge classification. Agreement between tests for the diagnosis of CP was evaluated by a kappa statistic. Of 45 patients screened, 15 declined and 30 (12 men and 18 women, mean age 44 years) underwent diagnostic EUS. Of these, 18 (60%) had suspected CP and 16 underwent attempted biopsy. Calcific pancreatitis in two patients precluded EUS-TCB. EUS-TCB results were as follows: probable CP (1), normal pancreas (8), nondiagnostic (6), device malfunction (1). Complications after EUS-TCB occurred in two patients with normal pancreatic biopsies were the following: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were hospitalized and discharged within 23 hours. Six patients refused ERCP and two (per protocol) did not undergo ERCP. For the remaining 22, agreement between diagnostic EUS and ERCP was moderate (kappa, 0.40). Agreement between EUS and ERCP with EUS-TCB were poor (kappa, 0) and fair (kappa, 0.25), respectively. Transgastric EUS-TCB of suspected nonfocal CP infrequently demonstrates histologic CP in clinically suspected disease. Because of potential complications and limited diagnostic yield, this technique is not currently recommended for evaluation of these patients.
Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tis... more Histologic biopsy of the liver is often essential for diagnosing hepatic parenchymal disease. Tissue acquisition is traditionally obtained by a surgical, transvascular, or percutaneous route. To describe our initial experience with EUS-guided Tru-cut biopsy (EUS-TCB) of benign liver disease. A prospective case series. A tertiary-referral hospital in Indianapolis, Indiana. Consecutive subjects undergoing EUS with suspected hepatic parenchymal disease. EUS-TCB of the liver. Liver biopsy specimen yield, diagnosis, and procedural complications. Specimens were routinely stained with hematoxylin and eosin and with special stains for reticulin, iron, and trichome. Each case was reviewed by a single experienced pathologist for the number of portal spaces, total specimen length, and final diagnosis. An adequate specimen was defined as 6 or more complete portal tracts. Between February 2007 and March 2008, 21 consecutive patients (mean age 45 years; 13 women) were evaluated. The most common indications for liver biopsy were suspected nonalcoholic steatohepatitis (n = 9), intrahepatic cholestasis (n = 4), and suspected cirrhosis (n = 3). Transgastric biopsy (median 3 passes, range 1-4) into the left lobe (n = 18) or both the left and caudate lobe (n = 3) yielded a median total specimen length of 9 mm (range 1-23 mm). The median total number of portal tracts in the specimen was 2 complete (range 0-10) plus 3 partial (range 0-8) tracts. Six or more complete portal tracts were present in 6 of 21 (29%). A histologic diagnosis was obtained in 19 of 21 (90%). There were no complications. The small sample size and low-risk population. In our initial experience, transgastric EUS-TCB of suspected benign liver disease by using a 19-gauge needle appears safe and feasible. Samples obtained are usually smaller than those traditionally considered adequate for histologic assessment. Further refinement of this technique appears indicated.
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