Geographic and patient variation among Medicare beneficiaries in the use of follow-up testing after surgery for nonmetastatic colorectal carcinoma

BACKGROUND

There are a paucity of data supporting the routine use of follow-up testing to detect recurrent disease after potentially curative initial surgery in patients with nonmetastatic colorectal carcinoma.

METHODS

Using the population-based Surveillance, Epidemiology, and End Results (SEER) registry, all patients age > or =65 years with local or regional colorectal carcinoma who were diagnosed in 1991, underwent surgical resection, and survived at least 6 months after diagnosis were identified. All inpatient, hospital outpatient, and physician/supplier Medicare claims from 6 months after diagnosis through 1994 were examined for follow-up procedures of interest. Procedure use during follow-up was compared across patient groups using both bivariate and multivariate analyses.

RESULTS

A total of 5716 patients were identified, with 1.3% found to have developed subsequent primary tumors of the colon or rectum, and 74% surviving through 1994. One or more procedures of interest were performed in 88% of patients; the most commonly performed tests were liver enzymes, chest X-rays, colonoscopy, and computed tomography scans. Lower rates of testing generally were observed with older age groups, patients with fewer comorbidities, and patients who did not survive through the follow-up period. Among all procedures studied, there also was significant variation in the rates of testing across the 9 SEER areas, varying from 1.5-fold to 3.6-fold. The geographic variation persisted in multivariate models adjusting for potentially confounding factors.

CONCLUSIONS

The current study found significant variability in the use of follow-up procedures, with the most striking differences apparent across geographic regions. Further studies are needed to determine the underlying reasons for the disparities, as well as the impact of surveillance on patient outcomes.

Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis

BACKGROUND

The ability to identify common bile duct stones by noninvasive means in patients with acute biliary pancreatitis is limited. The aim of this study was to prospectively evaluate the ability of endosonography (EUS) to identify cholelithiasis and choledocholithiasis and predict disease severity in patients with nonalcoholic pancreatitis.

METHODS

EUS was performed immediately before endoscopic retrograde cholangiopancreatography (ERCP) by separate blinded examiners within 72 hours of admission. Gallbladder findings were compared between EUS and transabdominal ultrasonography (US). Using endoscopic extraction of a bile duct stone as the reference standard for choledocholithiasis, the diagnostic yield of EUS was compared with transabdominal US and ERCP. Features identified during endosonographic imaging of the pancreas were correlated with length of hospitalization.

RESULTS

Thirty-six patients were studied. EUS and transabdominal US were concordant in their interpretation of gallbladder findings in 92% of patients. The sensitivity of transabdominal US, EUS, and ERCP for identifying choledocholithiasis was 50%, 91%, and 92% and the accuracy was 83%, 97%, and 89%, respectively. Length of hospital stay was longer in patients with peripancreatic fluid (9.2 vs. 5.7 days, p < 0.1) and shorter in patients with coarse echo texture (2.6 vs. 7.2 days, p < 0.05) demonstrated on EUS.

CONCLUSIONS

EUS can reliably identify cholelithiasis and is more sensitive than transabdominal US in detecting choledocholithiasis in patients with biliary pancreatitis. EUS may be used early in the management of patients with acute pancreatitis to select those who would benefit from endoscopic stone extraction. The utility of EUS for predicting pancreatitis severity requires further investigation.

Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay

BACKGROUND

The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy).

METHODS

Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices.

RESULTS

Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (-31%: 95% CI [-44%, -14%).

CONCLUSION

In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery.

Clinical implications of endoluminal ultrasonography using through-the-scope catheter probes

BACKGROUND

Ultrasound catheter probe-assisted endosonography is a relatively new technique. The aim of this prospective multicenter study was to determine its potential clinical impact by assessing changes in diagnostic and therapeutic management affected by catheter probes compared with ultrasound endoscopes.

METHODS

Endosonographers at three centers selected theoretic diagnostic and therapeutic plans that would be followed if neither catheter probes nor ultrasound endoscopes were available. Patients with suitable lesions underwent endosonography with catheter probes followed by an ultrasound endoscope. Diagnostic and therapeutic plans were noted after each examination.

RESULTS

Sixty-six patients, of whom 15 had a stenotic esophageal cancer, 39 had a mucosal or submucosal lesion, and 12 had a stricture of the pancreaticobiliary system or the gastrointestinal tract, were enrolled. If neither form of endosonography were available, invasive or surgical diagnostic procedures would have been performed on 23 (35%) patients and surgical therapy would have been planned in 31 (47%) patients. Catheter probe-assisted ultrasonography and endoscopic ultrasonography led to a less invasive diagnostic plan in 11 (16%) and 12 (18%) patients and a less invasive therapeutic plan in 10 (15%) and 14 (21%) patients, respectively (p > 0.1 for differences).

CONCLUSIONS

Catheter probe-assisted endosonography has a modest effect on diagnostic and therapeutic management, comparable with endoscopic ultrasonography in the same patients. The vast majority of effected changes are toward less invasive management.

Endoscopic practice for upper gastrointestinal hemorrhage: differences between major teaching and community-based hospitals

BACKGROUND

Differences in endoscopic practice in major teaching and community hospitals are not known.

METHODS

A total of 1031 consecutive patients discharged from 13 hospitals (4 major teaching, 9 others) in 1994 with upper gastrointestinal hemorrhage were studied. Data obtained from chart abstraction included endoscopic findings and therapy and selected outcomes. Multivariable analyses adjusted for admission severity of illness and endoscopic findings.

RESULTS

Rates of endoscopy were similar between patients admitted to major teaching and other hospitals, although procedures to control hemorrhage were used more often in major teaching hospitals (35% vs. 19%, p < 0.001). Use of endoscopic therapy was higher in major teaching hospitals for lesions in which therapy is recommended, as well as other lesions. Recurrent bleeding was also more common in major teaching hospitals (14.3% vs. 7.8%, p = 0.001), and the difference persisted in multivariable analysis (odds ratio 1.69: 95% CI [1.09 to 2.64], p = 0.02). Unadjusted and adjusted length of stay were somewhat shorter in major teaching hospitals.

CONCLUSIONS

There was large variation in the use of endoscopic therapy, with higher rates observed in major teaching hospitals for lesions in which therapy is recommended, as well as other stigmata. Further studies are needed to better define the reasons for the practice variation and to assess the impact on other outcomes such as readmission and costs.

Endoscopic ultrasound in restaging of esophageal cancer after neoadjuvant chemoradiation

BACKGROUND

Endoscopic ultrasound (EUS) is established as the most accurate method currently available for determining the depth of primary cancer invasion (T stage). Standard EUS criteria may not be accurate in assessing depth of cancer invasion and nodal status after patients have received chemotherapy or radiotherapy.

METHODS

We conducted a prospective study to determine whether EUS estimation of tumor size could be used to assess response to preoperative chemoradiation. Using EUS, TNM stage was assessed in 31 patients (22 men, 9 women; mean age 62 years) with cancer of esophagus or cardia (19 adenocarcinoma, 12 squamous cell cancer) before initiation of combined radiation and 5-fluorouracil/cisplatin (and/or carboplatinum) chemotherapy. The cross-sectional area of the tumor in the transverse plane at the location where the tumor had maximal thickness was calculated to estimate tumor size. EUS staging and measurement of maximal cross-sectional area were repeated at completion of chemoradiation just before surgery. Response to preoperative chemoradiation was defined as 50% reduction in maximal cross-sectional area. Surgical staging was compared between responders and nonresponders.

RESULTS

Eight patients who did not undergo surgery were excluded from analysis. EUST stage in the remaining 23 patients before therapy was as follows: 3 T2, 16 T3, and 4 T4. After chemoradiation, EUS T staging was changed in 6 patients (3 T4 downstaged to T3, 2 T3 downstaged to T2, and 1 T3 downstaged to T1). At surgical pathological examination, 3 patients had no residual tumor in the esophagus (T0), 5 had T1, 3 had T2, 10 had T3, and 2 had T4 tumors. EUS T staging accuracy after adjuvant therapy was only 43%. Maximal cross-sectional area decreased from a mean of 5.5 +/- 2.4 to 1.6 +/- 0.9 cm2 in responders, whereas maximal cross-sectional area went from 7.0 +/- 3.0 to 5.4 +/- 2.2 cm2 in nonresponders (p = 0.009). Ten of thirteen patients with at least a 50% reduction in maximal cross-sectional area (responders) had T0, T1, or T2 tumors at surgery, whereas 9 of 10 nonresponders had T3 or T4 tumors at surgery (p = 0.001).

CONCLUSIONS

(1) Standard EUS staging criteria are not accurate after neoadjuvant chemoradiation, (2) reduction in maximal cross-sectional area of tumor appears to be a more useful measure for assessing response of esophageal cancer to preoperative chemoradiation, and (3) responders have an increased likelihood of downstaging at surgery than nonresponders.

Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis

BACKGROUND

Choledocholithiasis is a major source of morbidity among patients undergoing cholecystectomy for symptomatic gallstones. There is no consensus on the best approach to diagnosing bile duct stones. We compared the safety, accuracy, diagnostic yield, and cost of EUS- and ERCP-based approaches.

METHODS

Sixty-four consecutive pre- and post-cholecystectomy patients referred for endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis were prospectively evaluated in a blinded fashion. All were stratified into risk groups using predefined criteria. Endoscopic ultrasonography (EUS) and ERCP were sequentially performed by two endoscopists.

RESULTS

The success rates of EUS and ERCP were 98% and 94%, respectively. The accuracy of EUS for diagnosing choledocholithiasis was 94%. EUS provided an additional or alternative diagnosis to bile duct stones in 21% of patients. The complication rate of EUS was significantly lower than diagnostic ERCP. An EUS-based strategy costs less than diagnostic ERCP in patients with low, moderate, or intermediate risk.

CONCLUSIONS

EUS is comparably accurate, but safer and less costly than ERCP for evaluating patients with suspected choledocholithiasis. It is useful in patients with an increased risk of having common bile duct stones based on clinical criteria and those with contraindications for or prior unsuccessful ERCP. EUS may enable selective performance of ERCP and improve the cost-effectiveness of diagnosing choledocholithiasis.

The effectiveness of early endoscopy for upper gastrointestinal hemorrhage: a community-based analysis

OBJECTIVES

The effectiveness of upper endoscopy in unselected patients with upper gastrointestinal hemorrhage has not been well studied. This study was undertaken to identify factors associated with the performance of early endoscopy (ie, within 1 day of hospitalization) and, after adjusting for these factors, to determine associations between early endoscopy and in-hospital mortality, length of stay, and performance of surgery.

METHODS

Subjects in this observational cohort study were 3,801 consecutive admissions with upper gastrointestinal hemorrhage to 30 hospitals in a large metropolitan region. Demographic and clinical data were abstracted from hospital records. A multivariable model based on factors that potentially could relate to the decision to perform endoscopy was developed to determine the propensity (0 to 100%) for early endoscopy in each patient.

RESULTS

Early endoscopy was performed in 2,240 patients (59%), and although it was not associated with mortality after adjusting for severity of illness among all patients, it was associated with a higher risk of death for patients in the lowest propensity group. Early endoscopy was associated with a lower likelihood of upper gastrointestinal surgery in all patients and in the two highest propensity groups and with a shorter length of stay in the entire cohort and in all subgroups.

CONCLUSIONS

In the absence of specific contraindications, early endoscopy should be considered because of associated reductions in length of stay and surgical intervention. Further studies are needed to identify subgroups in whom the procedure may be associated with adverse effects on survival.

Determination and validation of a predictive model for Clostridium difficile diarrhea in hospitalized oncology patients

BACKGROUND

Clostridium difficile colitis in the cancer patient receiving chemotherapy is a frequent cause of morbidity which may prolong hospitalization. Techniques for identifying infection often delay the initiation of therapy.

PATIENTS AND METHODS

In this retrospective case-control analysis, we identified predictors for C. difficile-associated diarrhea in 29 patients hospitalized from 1988 to 1993 on a hematologic malignancy/bone marrow transplant unit (hospital A). We then validated our model with 58 C. difficile cases and 74 controls admitted to an oncology unit from a different institution (hospital B).

RESULTS

We found that low intensity of chemotherapy (P < 0.001), lack of parenteral vancomycin use (P = 0.03) and hospitalization within the past two months (P = 0.05) were independently predictive of C. difficile colitis by multivariate analysis. These variables were weighted for predictive capability using a receiver operator characteristic score; low intensity chemotherapy was assigned two points, lack of parenteral vancomycin received one point and prior hospitalization one point (P < 0.001 by chi 2 for trend). The receiver operating characteristic (ROC) curve areas were 0.78 for patients at hospital A and 0.70 at hospital B indicating moderate drop off in discrimination. Compared to hospital A patients, hospital B patients hospitalized between 1989 and 1994 were more often women (P = 0.04), received less systemic vancomycin (P = 0.01), were less frequently neutropenic (P < 0.05), and received less intense chemotherapy regimens (P < 0.05). Despite these differences in demographics in patients between these institutions, our predictive model was validated in hospital B patients (P = 0.02 by chi 2 for trend).

CONCLUSIONS

The results of this study may help clinicians predict the risk of C. difficile disease in the hospitalized immunocompromised oncology patient and may help guide empiric therapy while awaiting results of stool toxin assays.

Enteroscopy for the initial evaluation of iron deficiency

BACKGROUND

Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy in patients with iron-deficiency anemia. The aim of this study was to prospectively measure the additional diagnostic yield of examining the jejunum at the time of upper endoscopy in patients with iron-deficiency anemia.

METHODS

Asymptomatic patients with newly diagnosed iron-deficiency anemia who had no identifiable source of blood loss at colonoscopy underwent standard esophagogastroduodenoscopy with the Olympus SIF100L enteroscope followed by overtube-assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. Biopsy samples from the small bowel were taken when a bleeding lesion was not identified.

RESULTS

Thirty-one consecutive patients (13 men, mean age 71) with no gastrointestinal symptomatology were studied. Eleven patients (35%) had a bleeding source that required only esophagogastroduodenoscopy for identification; 8 patients (26%) had a source only in the jejunum; 2 patients (6%) (one with sprue) had a source in upper tract as well as jejunum. The enteroscopy was rated as causing minimal or mild discomfort in 25 of 31 patients (81%). Using Medicare reimbursement figures, a strategy of performing esophagogastroduodenoscopy first would have cost $656 per patient, whereas the strategy of performing esophagogastroduodenoscopy with enteroscopy as the initial test in all patients costs $467 per patient.

CONCLUSIONS

Performance of push enteroscopy along with esophagogastroduodenoscopy increases the diagnostic yield from 41% to 67% when evaluating the upper gastrointestinal tract of asymptomatic patients with iron-deficiency anemia and, because of a lower cost, should be the preferred initial diagnostic test.

Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings

BACKGROUND

Push enteroscopy is indicated in patients with suspected small bowel gastrointestinal bleeding or small bowel mucosal disease. Our aim was to determine the diagnostic yield of enteroscopy, identify clinical predictors associated with findings, and measure frequency of management changes made on the basis of results.

METHODS

Endoscopy reports, office charts, and hospital charts were reviewed for 164 patients who had enteroscopy performed, primarily with a video enteroscope, during a period of 2 years. Data extraction included details of comorbid illnesses, associated risk factors, and previous endoscopies.

RESULTS

Indications for enteroscopy were suspected occult bleeding in 65, overt bleeding in 64, diarrhea in 20, and suspected mucosal disease in 15 patients. Diagnostic lesions, identified in 92 patients (56%), included 57 jejunal lesions (35%). In patients with overt bleeding, upper tract lesions were present more commonly in patients receiving nonsteroidal medication (54% versus 27%, p < 0.05). Jejunal vascular ectasia occurred more frequently in patients with documented vascular ectasias elsewhere in the gastrointestinal tract (34% versus 15%, p < 0.01). Missed lesions on previous upper endoscopy included large hiatal hernias with erosions in 10, peptic ulcers in 10, and vascular ectasias in 9 patients. Therapeutic interventions, made in 67 of 92 patients (73%) with diagnostic lesions, included small bowel resection in 12 (8%), endoscopic therapy in 21 (14%), and changes in medical regimen in 34 patients (22%).

CONCLUSIONS

Push enteroscopy with video enteroscopes has a moderate diagnostic yield. Positive findings frequently lead to therapy changes. Large hiatal hernias remain an under-recognized etiology of anemia. Repeat upper endoscopy should be considered before enteroscopy in patients taking nonsteroidals who develop overt bleeding.

Lack of gender and racial differences in surgery and mortality in hospitalized Medicare beneficiaries with bleeding peptic ulcer

OBJECTIVE

Determine the relation of race and gender to outcome from bleeding peptic ulcer.

DESIGN

Retrospective cohort study.

SETTING

All acute care hospitals in the United States.

PATIENTS

A 100% sample of hospitalized Medicare beneficiaries older than 64 years (n = 82,868) with a primary discharge diagnosis of peptic ulcer with hemorrhage.

MEASUREMENTS AND MAIN RESULTS

Surgical treatment was performed in 6.9% of patients, 30-day mortality was 8.5%, and average length of stay was 9.4 days. Surgery was somewhat more common in men than women (7.3% vs 6.5%, p < .001), and in whites than African Americans (6.9% vs 6.3%, p < .001), but neither race nor gender was associated with surgery in multivariable analysis adjusting for potentially confounding factors. Mortality rates were similar in African Americans and whites (8.5%), and somewhat higher in men than women (10.7% vs 9.3%, p < .001). In multivariable analysis, there was no difference in mortality across gender and racial groups. Although unadjusted and adjusted lengths of stay were longer for African Americans and shorter for men, the differences were modest (i.e., 16% increase and 6% decrease in multivariable analysis, respectively, p < .0001).

CONCLUSIONS

In this national sample, there is no significant gender or racial difference in therapy and outcome for patients with hemorrhagic peptic ulcer. The findings raise the possibility that studies that have shown race and gender differences in management of coronary artery disease and cancer may not be generalizable to other common diagnoses.

Endosonographic differentiation of benign and malignant stromal cell tumors

BACKGROUND

Endosonography (EUS) is a valuable technique for diagnosing gastrointestinal stromal cell tumors. However, EUS features that are predictive of malignancy in these tumors have not been defined.

METHODS

Videotapes and photographs of EUS examinations performed prior to surgical resection of 35 stromal cell tumors (9 malignant) were blindly reviewed by a single examiner. EUS features associated with malignancy were determined. Interobserver agreement in interpreting these features was then measured among a panel of five expert endosonographers who judged EUS videotapes of 35 resected stromal cell tumors (10 malignant).

RESULTS

Stepwise logistic regression analysis demonstrated that tumor size (diameter > 4 cm), irregular extraluminal border, echogenic foci, and cystic spaces were independently associated with malignancy in stromal cell tumors (p < 0.05). Interobserver agreement for irregular extraluminal border, echogenic foci, and cystic spaces, as measured by mean kappa statistic, was 0.43, 0.39, and 0.28, respectively. For the five experts, the sensitivity for detecting malignancy ranged between 80% to 100% when at least two of the three features were judged to be present. The likelihood of finding malignancy ranged between 0% to 11% for the experts when all three features were judged absent.

CONCLUSIONS

Tumor size and certain EUS features are useful for predicting malignancy in stromal cell tumors. Absence of these features indicates benign disease. Agreement among experts in interpreting these EUS features is fair to moderate.

Clinical variables associated with colorectal cancer on colonoscopy: a prediction model

OBJECTIVES

We prospectively evaluated the ability of various indications for colonoscopy to predict colorectal cancer.

METHODS

Indications and findings were prospectively recorded for 1223 consecutive colonoscopies performed during an 18-month period at a University Hospital. Colonoscopies performed on 981 patients for indications which included colorectal cancer in the differential diagnosis were included in the study. A group of 653 patients was randomly selected to derive a model predictive of colorectal cancer at colonoscopy; the remaining 328 patients were used to validate the model.

RESULTS

Colorectal cancer was found in 44/981 patients (4.5%). Univariate analysis of the derivation set showed that age > 55, occult bleed, anemia, iron deficiency, weight loss, and abnormal CT scan were associated with finding colorectal cancer at colonoscopy in the derivation set, p < 0.05. History of polyps was negatively associated with finding colorectal cancer. Stepwise selection was used to develop a predictive model by using three independent variables-age > 55, iron deficiency, and weight loss. Assigning a score of 1 to each variable, cancer was present in 0% [95% confidence intervals (CI), 0-0.6%], 5.3% (95% CI, 2.3-8.3%), and 17.9% (95% CI, 4.8-31%) of patients in the validation sample with a score of 0, 1, and > or = 2, respectively (p < 0.001 by chi2 for trend). The model was predictive of finding colorectal cancer at colonoscopy, independent of the location or stage of the cancer.

CONCLUSIONS

Age, iron deficiency, and weight loss are important independent predictors of colorectal cancer in patients referred for colonoscopy.

Clinical implications of endoscopic ultrasound: the American Endosonography Club Study

BACKGROUND

Despite increased clinical use of endoscopic ultrasound (EUS), there are little data regarding complications of EUS or its impact on patient management.

METHODS

A prospective multicenter study was completed to evaluate clinical outcomes of EUS. Before each EUS examination the endosonographer recorded further theoretical patient management plans as if EUS was unavailable. After the EUS, endosonographers recorded actual management plans based on EUS results. The actual management plan after EUS was compared to the theoretical management before EUS. Complications were assessed in short-term follow-up.

RESULTS

Four hundred twenty-eight subjects were enrolled. Of subjects able to be evaluated, EUS changed the treatment plan in 74%. Management changes of major importance occurred in 120 patients (31% of subjects able to be evaluated) and included decisions regarding surgery (62 patients), decisions regarding nonsurgical invasive management (36 patients), and decisions regarding further follow-up (22 patients). When there was a change in management, the change was to less costly, risky, or invasive management in 55%, to more costly/risky/invasive in 37%, and to equally costly/risky/invasive in 8%. Short-term follow-up was completed in 81% of subjects, with six complications identified (1.7%). Three complications were mild, two were moderate, one severe, and none fatal.

CONCLUSIONS

(1) Changes in management plan may occur in the majority of patients based on EUS results. (2) The management changes are often of major importance with regard to health care costs and safety, and are more often in the direction of less costly, risky, and invasive management. (3) EUS is safe in experienced hands.

Care of patients with upper gastrointestinal hemorrhage in academic medical centers: a community-based comparison

BACKGROUND & AIMS

A common perception among purchasers is that academic medical centers are inefficient and overutilize technology; however, little empirical information exists. The aim of this study was to compare treatment and outcomes of patients with upper gastrointestinal hemorrhage admitted to major teaching hospitals and other hospitals in a large metropolitan area.

METHODS

Data on 3801 consecutive eligible patients admitted to five major teaching hospitals and 25 other hospitals from 1991 to 1993 were obtained by review of medical records. Admission severity of illness was measured using validated multivariable models.

RESULTS

Rates of upper endoscopy were somewhat lower among the 1004 patients discharged from fellowship hospitals, compared with the other 2797 patients (82.9% vs. 85.6%; P < 0.05), and the use of other procedures was similar. Although patients admitted to fellowship hospitals tended to have a higher severity of illness, both unadjusted (6.3 +/- 9.0 vs. 7.1 +/- 7.5 days; P < 0.01) and risk-adjusted length of stay were somewhat shorter. Mortality rates were similar between hospitals, and patients admitted to fellowship hospitals were somewhat less likely to be transfused.

CONCLUSIONS

In patients with upper gastrointestinal hemorrhage, teaching hospitals do not appear to provide inefficient care or overutilize expensive treatments when compared with community facilities. These findings are noteworthy at a time when viability of academic centers and fellowship training is threatened.

Prospective assessment of colonoscopic intubation skills in trainees

INTRODUCTION

The American Society for Gastrointestinal Endoscopy recommends a minimum of 100 supervised colonoscopies prior to assessment of technical competence. To establish a measurable standard for competence and to assess this recommendation, performance of colonoscopies at a university hospital was studied.

METHODS

Colonoscopic preparation, surgical history, medication usage, technical maneuvers, extent of colon intubated, success rate, and cecal intubation time were prospectively monitored for first-year trainees, second-year trainees, and attendings.

RESULTS

Excluding patients with poor preparations or colonic resections, 496 colonoscopies were studied. First-year trainees (n = 5) required attending assistance in 73 of 79 (92%) procedures. Second-year trainees (n = 7), who had performed a mean of 123 colonoscopies prior to the study, required attending assistance in 37 of 102 (36.3%) procedures. Attendings (n = 7) successfully intubated the cecum in 297 of 315 (94.3%) colonoscopies in a median time of 10.5 minutes. Second-year trainees were less successful than attendings in cecal intubation (success rate = 84%, p < 0.05), and required more time (median = 14.5 minutes, p < 0.01). More technical maneuvers were performed, and a lesser extent of colon was intubated, during trainee colonoscopies.

CONCLUSIONS

We propose a 90% success rate and a median cecal intubation time of less than 15 minutes as reasonable standards for measuring technical competence. Trainees do not achieve this standard after the performance of 100 supervised colonoscopies.

Methylene blue selectively stains intestinal metaplasia in Barrett's esophagus

BACKGROUND

Specialized columnar epithelium in Barrett's esophagus resembles gastric intestinal metaplasia, which selectively stains with methylene blue.

METHODS

We prospectively evaluated the safety, accuracy, reproducibility, cost, and diagnostic yield of methylene blue-directed biopsy in detecting specialized columnar epithelium and dysplasia in Barrett's esophagus. We performed upper endoscopy with methylene blue-directed biopsy and obtained 236 large cup biopsy specimens (145 stained, 91 unstained) from 14 patients with Barrett's esophagus of any length (Group 1) and 12 control patients. Biopsy specimens were independently examined by two pathologists unaware of the endoscopic results.

RESULTS

Methylene blue stained specialized columnar epithelium in 18 of the 26 patients, including those with intramucosal carcinoma (1), high-grade dysplasia (1), and indefinite/low-grade dysplasia (6). Methylene blue staining pattern, which was focal in 72% and diffuse in 28% of patients, was reproduced in 8 patients who had repeat staining within 4 weeks. The overall accuracy of methylene blue staining for detecting specialized columnar epithelium was 95%. The diagnostic yield of methylene blue staining for specialized columnar epithelium in "control" patients was 42%. The risk for dysplasia in stained biopsy specimens was greater than in unstained ones (odds ratio 17.7, p = .0004).

CONCLUSIONS

Methylene blue mucosal staining is a safe, inexpensive, reproducible, and highly accurate method of diagnosing specialized columnar epithelium in Barrett's esophagus.

Endoscopic ultrasonography

Optimal treatment of gastric carcinoma requires accurate staging as there are marked differences in the prognosis of early and advanced gastric cancer which influence the decision for surgical resection versus nonsurgical palliation. Endoscopic ultrasonography (EUS), by virtue of its considerable accuracy, has become the method of choice for regional staging of gastric cancer. EUS is unique in its ability to image the gastric wall as a 5-layer structure that correlates with actual histological layers. Thus, tumor depth can be imaged very precisely. Peritumor inflammation is the most common cause for overstaging by EUS; difficulty in determining tumor involvement of, but not through, the subserosa is another important reason for inaccurate staging. EUS is able also to detect small lymph nodes in the perigastric region. Although assessment of malignancy in nodes can be difficult, ultrasound-guided fine needle aspiration cytology appears to be an accurate method to determine lymph node status. Surgery remains the standard treatment for gastric cancer, but new methods of endoscopic resection combined with high-frequency ultrasound may hold promise for future treatment of early gastric cancer. In addition to current radial and sector scanning instruments, recently introduced high-frequency ultrasound probes enhance the diagnostic possibilities of this technology.

Prognosis of esophageal cancers preoperatively staged to be locally invasive (T4) by endoscopic ultrasound (EUS): a multicenter retrospective cohort study

BACKGROUND

Endosonography is a significant advance in the preoperative staging (TNM classification) of esophageal cancer. Its accuracy for evaluating depth of tumor invasion is over 80%.

METHODS

A multicenter retrospective cohort study of patients with esophageal carcinomas defined to be invasive (T4) by endosonography was performed to compare the survival of surgically and nonsurgically treated patients. Median survival time, overall mortality, and Kaplan-Meier survival curves were compared by treatment group. Univariate and Cox regression analysis were used to evaluate the effects of various prognostic factors and treatment on the risk of death.

RESULTS

A total of 79 patients were studied. The surgical group (Group I, n = 42) was significantly younger and had more distal tumors (adenocarcinomas) than the nonsurgical group (Group II, n = 37). Endosonography was significantly more accurate than CT scanning in identifying tumor invasion (87.5% versus 43.8%, respectively, p = .0002). Overall mortality rate was not significantly different between treatment groups; 59.5% of the surgical group and 64.9% of the nonsurgical group were dead at follow-up (p = 0.65). Similarly, the median survival times of Group I and Group II patients were similar (5.2 and 7.0 months, respectively, p = 0.50). Survival curves for the two groups were almost overlapping (log rank test, p = 0.84). Even after adjusting for age, histologic diagnosis, tumor location, and regional lymph node status, surgical treatment did not significantly influence survival (p = 0.24).

CONCLUSIONS

Endosonography accurately identifies patients with invasive T4 tumors who have a poor prognosis. This prognosis is independent of mode of therapy.

Duplex Doppler endosonography in the diagnosis of splenic vein, portal vein, and portosystemic shunt thrombosis

BACKGROUND/AIMS

Endoscopic ultrasonography is a promising procedure for imaging mesenteric vascular structures.

METHODS

Duplex and color Doppler endosonography were used to prospectively evaluate 20 asymptomatic paid volunteers. Subsequently, 11 patients with nondiagnostic transabdominal ultrasound and suspected thrombosis of the splenic and/or portal veins or a portosystemic shunt were evaluated with duplex endosonography. The final diagnosis was based on CT, angiography, and/or surgery or autopsy findings in 9 of 11 patients.

RESULTS

In normal volunteers, mesenteric vessel flow velocities and diameters were similar to previously described values. In 10 of the 11 patients with failed transabdominal ultrasound, duplex endosonography was able to provide the correct diagnosis (accuracy of ultrasound 0% versus EUS 91%, p < .001). Mean portal vein diameter was greater in the patient group than in the normal volunteers (18.5 mm versus 10.7 mm, p < .001) and all of the normal volunteers had a portal vein diameter less than 13 mm. No complications were experienced.

CONCLUSION

Duplex endosonography allows visualization of the intra-abdominal vasculature and can be considered when transabdominal ultrasound is nondiagnostic in patients with suspected thrombosis of their splenic vein, portal vein, or portosystemic shunt. EUS is able to identify indirect findings of portal hypertension including portal vein enlargement and venous collaterals.

Traveler's diarrhea

A variety of infectious enteric pathogens (bacterial, viral, and protozoal) can lead to a systemic diarrheal illness in international travelers traveling from industrialized countries to developing areas of the world. Many of the agents that lead to this syndrome have been identified, and their mode of transmission has been defined. Prophylactic measures are advisable, and effective treatment options are available. This article also discusses issues important in the management of patients who develop a chronic diarrheal illness after travel.