Clinical implications of endoscopic ultrasound: the American Endosonography Club Study

The impact of endoscopic ultrasound on the management and outcome of patients with oesophageal cancer: an update of a systematic review

AIM

To provide an updated systematic review concerning the impact of endoscopic ultrasound (EUS) in the modern era of oesophageal cancer staging.

MATERIALS AND METHODS

To update the previous systematic review, databases including MEDLINE and EMBASE were searched and studies published from 2005 onwards were selected. Studies reporting primary data in patients with oesophageal or gastro-oesophageal junction cancer who underwent radiological staging and treatment, regardless of intent, were included. The primary outcome was the reported change in management after EUS. Secondary outcomes were recurrence rate and overall survival. Two reviewers extracted data from included articles. This study was registered with PROSPERO (CRD42021231852).

RESULTS

Eighteen studies with 11,836 patients were included comprising 2,805 patients (23.7%) who underwent EUS compared to 9,031 (76.3%) without EUS examination. Reported change of management varied widely from 0% to 56%. When used, EUS fine-needle aspiration precluded curative treatment in 37.5%-71.4%. Overall survival improvements ranged between 121 and 639 days following EUS intervention compared to patients without EUS. Smaller effect sizes were observed in a randomised controlled trial, compared to larger differences reported in observational studies.

CONCLUSION

Current evidence for the effectiveness of EUS in oesophageal cancer pathways is conflicting and of limited quality. In particular, the extent to which EUS adds value to contemporary cross-sectional imaging techniques is unclear and requires formal re-evaluation.

Adverse events and mortality: comparative analysis between diagnostic and interventional endoscopic ultrasound

BACKGROUND AND AIMS

Escalating an indication of EUS for diagnosis and treatment justifies the evaluation of the conditions associated with the adverse events (AE) and related deaths. The aim is to evaluate and compare the incidence of AE and deaths after diagnostic-EUS (D-EUS) and interventional-EUS (I-EUS).

METHODS

This retrospective study included patients undergoing D-EUS and I-EUS, in two centers for 28 years (03/1992 to 12/2019). Were noted parameters such as: age, gender, indication of EUS, modality, time of occurrence and severity of AE, type of treatment imposed and whether there was death. Descriptive analysis was performed using means, standard deviation and frequencies of the variables of interest.

RESULTS

13,196 procedures performed, 9843 D-EUS and 3353 I-EUS. Thirty-seven (0.3%) had AE with six deaths (0.04%). The overall rate of AE for D-EUS and I-EUS was 0.08% and 0.86%, respectively (p > .05). Three deaths (0.03%) occurred after D-EUS and three (0.09%) after I-EUS. AE were immediate and early in 70% and 30%, respectively, with no late complications. Perforation was detected immediately in 80% and early in 20%, being more frequent after D-EUS than I-EUS. Acute pancreatitis occurred immediately in 70% and early in 30%. The AE were mild, moderate, and severe in 35.1%, 27%, and 37.8%, respectively. Overall, D-EUS presented the majority of AE as severe (87.5%), while I-EUS presented mild AE in most cases (41.4%), followed by severe complications (24.1%).

CONCLUSIONS

Despite the low incidence of AE and mortality after EUS, the occurrence of severe complications, especially perforation in D-EUS, may support the review of therapeutic protocols, aiming to ensure that a quality and safety process is implemented in the practice of EUS.

Regional differences in use of endoscopic ultrasonography in Ontario: a population-based retrospective cohort study

BACKGROUND

Endoscopic ultrasonography is a safe and accurate modality for evaluating and managing hepatobiliary and gastrointestinal conditions (malignant and nonmalignant); its use is increasing. The aim of this study was to describe regional trends in the use of endoscopic ultrasonography in Ontario.

METHODS

We conducted a population-based retrospective cohort study using health administrative databases. We identified all patients who underwent an endoscopic ultrasound procedure in Ontario from 2003 to 2011 using physician billing data. Patient, physician and institution characteristics were examined. The primary outcome was use of endoscopic ultrasonography.

RESULTS

We identified 9076 endoscopic ultrasound procedures performed in 8001 patients (3858 women [48.2%]; median patient age at first procedure 59 years). A total of 3066 procedures (33.8%) involved fine-needle aspiration. Use of endoscopic ultrasonography increased 17-fold over the study period. In 2011, people living in the health region with the highest rate of use of endoscopic ultrasonography were more than 4 times more likely to undergo the procedure than people living in the health region with the lowest rate of use (standardized rate 61.6 v. 12.9 per 100 000). About 7 in 10 endoscopic ultrasound procedures were performed in an academic institution or regional cancer centre. All 17 endoscopists performing endoscopic ultrasonography during the study period practised in urban areas.

INTERPRETATION

Although the use of endoscopic ultrasonography increased over time in Ontario, there were marked regional differences in use. Provincial needs- and evidence-based initiatives may be needed to narrow the regional gaps in provision of endoscopic ultrasound services in the province.

The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract

Introduction

The identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract.

Methods

Retrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed.

Results

324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2 cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p < 0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications.

Conclusion

EUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.

Iatrogenic pharyngoesophageal perforations treated with fully covered self-expandable metallic stents (with video)

BACKGROUND

Iatrogenic pharyngoesophageal perforations are a rare but serious complication of endoscopy. Surgical and non-surgical approaches have been reported but result in a significant morbidity and extended hospital stay. Therefore, an unmet need exists for an alternative management technique. We demonstrate a new endoscopic approach for the management of iatrogenic pharyngoesophageal perforations through the use of esophageal fully covered self-expandable metallic stents (FCSEMS).

PATIENTS AND METHODS

Two patients who underwent flexible endoscopy each suffered a large iatrogenic perforation detected intraprocedurally. After emergency intubation, an esophageal FCSEMS was deployed in the hypopharynx and the patient admitted to the intensive care unit. On day 3, the patients underwent an esophagogastroduodenoscopy with stent removal.

RESULTS

There was complete closure of the perforations on day 3. The patients were extubated and subsequently tolerated a soft diet. The patients were discharged home on day 4.

CONCLUSIONS

The placement of a removable FCSEMS in the setting of an acutely diagnosed perforation may be a suitable minimally invasive approach for the management of iatrogenic pharyngoesophageal perforations.

Evolving role of endoscopic ultrasonography-guided fine-needle aspiration in tumor staging and treatment of patients with carcinomas of the upper gastrointestinal tract

INTRODUCTION

Treatments such as neoadjuvant chemotherapy and endoscopic mucosal resection for upper gastrointestinal carcinomas (UGC) necessitates preoperative staging evaluation of lymph nodes. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) of lymph nodes provides more accurate staging than EUS alone. Our study investigates the role of EUS-FNA in the staging/treatment of patients with UGC.

MATERIALS AND METHODS

We searched our database for patients who had EUS-FNA staging of lymph nodes for UGC over 1 year. The cytologic diagnoses were compared with clinical, radiographic, EUS-determined staging, and patient follow-up data. All EUS/EUS-FNA procedures used a standard radial and/or linear echo endoscope. Direct smears from the aspirated material were stained by Papanicolaou and Diff-Quik methods.

RESULTS

We studied 84 patients with esophageal or gastroesophageal junction carcinomas and 15 patients with gastric carcinomas. EUS-FNA confirmed N0 status for 100% of patients with T1 and T2 tumors and for 93% of patients with T3 tumors. Patients with T1N0 carcinomas confirmed by EUS were selected for endoscopic mucosal resection. All patients with gastric carcinomas had EUS-determined stage T3 and above tumors. Based on primary tumor stage, all patients with gastric carcinomas received neoadjuvant chemotherapy.

CONCLUSIONS

Cytologic diagnosis by EUS-FNA agreed with EUS nodal staging in 77% of the patients with UGC. EUS-FNA was useful to select patients with T1N0 esophageal or gastroesophageal junction carcinomas for endoscopic mucosal resection. EUS-FNA did not contribute significantly in treatment of patients with higher stage tumors whose disease was down-staged to N0 by EUS-FNA. These patients received neoadjuvant chemotherapy based on the status of the primary tumor.

Health resource utilization and multidisciplinary impact of endoscopic ultrasonography in a tertiary referral medical center

BACKGROUND

Endoscopic ultrasound (EUS) is a resource-intensive endoscopic procedure, but may result in high downstream health resource utilization and multispecialty impact. Our aim was to examine the downstream impact of EUS by specialty and by indication.

METHODS

A retrospective chart review was performed at an academic medical center for patients for whom EUS represented the first point of contact at the study institution within a 20-month period.

RESULTS

A total of 552 EUS procedures were reviewed and 208 represented the first point of contact. The most common principle indication involved the pancreas (n = 117, 56%). Downstream health utilization was calculated for an average of 313 days postprocedure (range: 35-632 days). Following unique referral for endoscopic ultrasound, 52% of the patients in the study were retained within the institution for further management and, of these, 34% had a major intervention in the form of surgery or chemoradiotherapy. Compared with other indications, patients presenting with a pancreatic mass were significantly more likely to remain in the study institution for further management (62% versus 39%, p = 0.005), were more likely to have a downstream surgery (29% versus 14%, p = 0.020) and were more likely to have downstream chemo-radiotherapy (11% versus 3%, p = 0.012).

CONCLUSIONS

EUS represents a unique portal of entry into tertiary referral medical centers. First point of contact EUS referrals are associated with major downstream health resource utilization and significantly increased utilization for mass lesions of the pancreas.

Which patients with dilated common bile and/or pancreatic ducts have positive findings on EUS?

BACKGROUND

Patients with dilated common bile duct (CBD) (>7mm) and/or pancreatic duct (PD) on abdominal imaging are often referred for endoscopic ultrasound (EUS). In many cases, the EUS shows no obvious etiology for the dilated ducts.

OBJECTIVE

Find clinical factors that may predict which patients are more likely to have positive findings on EUS to explain the etiologies for the dilated ducts.

DESIGN

Retrospective database analysis.

SETTING

Tertiary-care university hospital.

PATIENTS

Patients referred for EUS for dilated CBD and/or PD from January 2004 to February 2010 were included in this study. Only patients without an obvious etiology for the dilated ducts on abdominal imaging were included.

INTERVENTIONS

An EUS was performed by using either a radial echoendoscope or a linear endoscope to evaluate the common bile duct and/or the pancreatic duct. When appropriate fine needle aspiration of the mass or cyst was performed.

MAIN OUTCOME MEASUREMENTS

The characteristics of patients who had positive findings on EUS to explain the etiology of their dilated PD and/or CBD.

RESULTS

A total of 140 patients were included in the study with a mean age of 64 years, 51 (36%) male and 115 (82%) white. The majority of our patients had a presenting symptom of abdominal pain 105 (75%). 49 (36%) had elevated AST or ALT, 25 (8%) had an elevated bilirubin and 13 (23%) had an elevated lipase. EUS findings explained the dilated ducts in 54 (39%) of our patients, most common diagnoses included: CBD stone in 11 (8%), non-calcific chronic pancreatitis in 9 (6%), pancreatic mass in 8 (6%), IPMN in 7 (5%). On bivarate analysis patients who were older (p = 0.006), male (p = 0.001), had elevated LFTs (p = <0.001), had elevated lipase (p = 0.021) or had dilated CBD and PD (p = 0.007) were more likely to have an etiology for their dilated duct(s) discovered on EUS.

LIMITATIONS

A retrospective study with a small number of patients.

CONCLUSION

Older patients, males and those patients presenting with concurrent elevations in the AST/ALT and/or lipase were more likely to have an underlying etiology discovered on EUS. Furthermore, EUS may detect an undiagnosed pancreatic malignancy in patients presenting with unexplained duct dilation.

Dynamic changes of echogenicity and the size of the papilla of Vater before and after cholecystectomy

This study investigated the changes in echogenicity, as measured by endoscopic ultrasound, and the surface area of the papilla of Vater (PV) and their relationship with postoperative symptoms in a group of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. After cholecystectomy, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The surface area of the PV was larger than normal prior to surgery and increased after surgery. The healthy PV is isoechogenic, but 48% of all patients were anisoechogenic preoperatively, increasing to 61% at 3 months after surgery, and decreasing to 25% at 6 months postsurgery. There was no significant difference between the two patient groups, suggesting that the changes observed in the PV do not explain the presence of the atypical symptoms of PCS.

The Size of the Papilla of Vater and Its Relation to Its Height in Comparison with the Visibility of the Sphincter of Oddi before and after Cholecystectomy

This study investigated the changes in the surface area and height of the papilla of Vater (PV) and the visibility of the sphincter of Oddi complex (SOK) using endoscopic ultrasound (EUS) examinations of 80 patients with symptomatic gallstones before and at 3 and 6 months after cholecystectomy. Following surgery, 50 patients experienced early atypical symptoms characteristic of postcholecystectomy syndrome (PCS) and 30 patients were asymptomatic. The PV measurements were greater in all patients compared with normal reference values and increased significantly from before surgery to 3 months postsurgery. At 6 months postsurgery, both the surface area and height of the PV had significantly decreased to preoperative values but remained higher than normal. The proportion of patients with a visible SOK had increased by 3 months postsurgery but had reduced again by 6 months. There were no significant differences between symptomatic and asymptomatic patients, suggesting that the changes observed in the PV and SOK do not explain the presence of the atypical symptoms of PCS.

A study comparing endoscopic ultrasound (EUS) and computed tomography (CT) in staging oesophageal cancer and their role in clinical decision making

BACKGROUND AND AIM

Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular preoperative staging protocol in oesophageal cancer. At present, EUS is increasingly being used for preoperative locoregional staging of oesophageal cancer. The aim of this study is to compare EUS and CT findings and their role in clinical decision making.

METHODS

The CT staging of 30 patients with oesophageal carcinoma was compared with EUS. This is a single centre-based study, and the EUS was carried out by a single operator.

RESULTS

The mean age was 58.2 years. On EUS, one (3.3%), five (16.7%), 16(53.3%) and eight (26.7%) patients had T1, T2, T3 and T4 tumours, respectively, compared with CT which showed 12(40%), nine (30%) and seven (23.3%) patients with T2, T3 and T4 tumours. On CT, two (6.7%) were shown as no tumour (T0). EUS revealed lymph node involvement in 25 (83.3%) patients compared with CT which indicated lymph node involvement in seven (23.3%) patients. On EUS, coeliac node involvement was shown in four (13.3%) patients (M1). The TNM staging of CT and EUS were comparable in nine (30%) patients. EUS staging revealed a more advanced stage of oesophageal cancer in 17 (56.7%) patients. Preoperative EUS staging changed the decision of management in 15 (50%) patients (P < 0.005).

CONCLUSIONS

EUS staging revealed a more advanced stage of cancer in the majority of patients. It appears to be far more superior in detecting lymph node involvement compared with CT. Therefore, EUS may have a significant impact on deciding the treatment modality of a patient with oesophageal carcinoma.

The clinical utility of esophageal manometry

BACKGROUND AND AIMS

Esophageal manometry (EM) is performed to evaluate symptoms of chest pain and dysphagia, although its clinical utility is not known. The aim of this study was to evaluate the clinical utility of EM by determining whether EM provides new information, changes diagnoses, or alters patient management.

METHODS

Before performing EM, referring providers noted indications for the test, symptoms, previous tests performed, and medication use. After EM was completed, a follow-up questionnaire ascertained whether EM provided new information or changed the patient's diagnosis or management plan. Patients provided demographic information.

RESULTS

During a 12-month period, 569 EMs were performed and 444 were available for inclusion; 286 fully completed questionnaires were returned (64%) and are the basis for this analysis. The mean age (+/-SD) at the time of manometry was 52 (+/-15) years; 58% were women; 98% were white. EM was requested to assist placement of a pH measuring device (34%), and to evaluate symptoms of dysphagia (29%), chest pain (12%), or acid reflux (11%). Overall, 64% of EM were abnormal; 81% in gastroesophageal reflux disease patients, 74% in dysphagia, and 59% in chest pain. New information was obtained in 87% of patients, whereas a change in diagnosis occurred in 30% of patients, and management changed in 44% of patients.

CONCLUSIONS

EM is a clinically useful test because it frequently provides new information and often changes patient diagnosis and management. The clinical utility of EM is greatest in patients with dysphagia.

Downstream hospital charges generated from endoscopic ultrasound procedures are greater than those from colonoscopies

BACKGROUND & AIMS

Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies.

METHODS

We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures.

RESULTS

Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036).

CONCLUSIONS

Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

A guide for the diagnosis and management of gastrointestinal stromal cell tumors

Gastrointestinal stromal cell tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract and are frequently detected on routine endoscopy. Although only approximately 10-30% of GISTs are clinically malignant, all may have some degree of malignant potential. Preoperative determination of malignancy risk can be estimated from tumor size and location, but reliable histopathologic criteria are not currently available. Given such biological uncertainty, accurate diagnosis is essential to differentiate these lesions from other truly benign, subepithelial tumors. Endoscopic ultrasound-guided fine-needle aspiration has emerged as an important procedure to secure a tissue diagnosis of a GIST. When encountering GISTs, gastroenterologists are faced with challenging management decisions, especially in the face of small, incidentally discovered lesions. The majority of localized GISTs are managed via surgical resection, although a select few may be observed using serial endoscopic ultrasound examinations. This Review provides a general overview of GISTs, with an emphasis on their endoscopic diagnosis, the management of localized disease, and the management of incidentally discovered GISTs.

Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management

OBJECTIVES

With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS.

METHODS

All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded.

RESULTS

A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01-0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure.

CONCLUSIONS

CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.

Resource-intensive endoscopic procedures: do the dollars make sense?

BACKGROUND

The rapid development of endoscopic technologies over the past decade has led to an increased utilization of resource-intensive endoscopic procedures in clinical practice. These procedures are technically challenging, time consuming, and typically involve major equipment-related costs.

OBJECTIVE

To determine the economics associated with performing resource-intensive endoscopic procedures in a tertiary-referral center

DESIGN

A retrospective practice database review.

SETTING

A single, North American tertiary-referral medical center.

PATIENTS

All the patients whose initial contacts with the medical center were as outpatients for an EUS, EMR, or ERCP between July and November 2004.

MAIN OUTCOME MEASUREMENTS

Hospital charges, the cost of providing services, revenue, and net income from all services provided through June 2006.

RESULTS

Seventy patients were tracked. During the review period, these 70 patients generated a total of $2.9 million, or $42,126 per patient, in hospital charges. The net profit was $407,263 ($5790 per patient). Endoscopic services alone resulted in a loss of $424 per patient. Surgical services generated just over $300,000 in net profit.

CONCLUSIONS

Economics for only resource-intensive endoscopic procedures are not financially viable under the current health care reimbursement system. The first step to removing disincentives to performing these cost-effective procedures would appear to be an insistence that reimbursement be weighted equitably to ensure reasonable profitability.

The impact of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) on esophageal cancer staging: a survey of thoracic surgeons and gastroenterologists

Accurate staging of esophageal cancer is critical to achieving optimal treatment outcomes. End-oscopic ultrasound with fine needle aspiration (EUS-FNA) has emerged as a valuable tool for locoregional staging. However, it is unclear how different physician specialties perceive the benefit of EUS-FNA for esophageal cancer staging, and thus utilize this modality in clinical practice. A survey regarding utilization of EUS-FNA in esophageal cancer was distributed to 211 thoracic surgeons and 251 EUS-capable gastroenterologists. Seventy-six thoracic surgeons (36%) and 78 gastroenterologists (31%) responded to the survey. Most surgeons (75%) use EUS to stage potentially resectable esophageal cancer 75% of the time. Surgeons using EUS less often are less likely to have access to high-quality EUS services than their peers. Fewer surgeons believe EUS is the most accurate test for T and N-staging (84% and 71%, respectively) as compared with gastroenterologists (97% and 96%, P < 0.01 for both). Most endosonographers (68%) decide whether to dilate a malignant esophageal stricture to complete the staging exam on a case-by-case basis. Surgeons disagree as to whether involvement of celiac lymph nodes should preclude esophagectomy in distal esophageal cancer. While most thoracic surgeons have embraced EUS-FNA as the most accurate locoregional staging modality in esophageal cancer, this attitude is not fully reflected in utilization patterns due to a lack of quality EUS services in some centers. Controversial areas that warrant further study include dilation of malignant strictures to facilitate EUS staging, and the implication of involved celiac lymph nodes on management.

Systematic review of the impact of endoscopic ultrasound on the management of patients with esophageal cancer

OBJECTIVES

Although endoscopic ultrasound (EUS) staging of esophageal cancer is established in clinical practice, high-quality evidence about its impact on patient outcomes is not available. This study aims to determine the impact of EUS for esophageal cancer staging on patient management and survival.

METHODS

A systematic review was conducted using Medline, PreMedline, Embase, and The Cochrane Library. Included studies were (i) comparative studies reporting survival following EUS esophageal cancer staging, (ii) therapeutic impact studies reporting change in patient management following EUS. The quality of included studies was critically appraised.

RESULTS

One systematic review, five studies reporting therapeutic impact, and two studies reporting patient survival were identified. The design and quality of the therapeutic impact studies varied widely. Management changed in 24-29 percent of patients following EUS staging of esophageal cancer (two studies). No studies provided data on the avoidance of surgery for this indication. One retrospective cohort study with historical control found EUS staging of esophageal cancer improved patient survival; a second study with similar design limitations did not find a survival benefit for EUS staging in patients undergoing resection. These studies had a high potential for bias, limiting the value of these findings.

CONCLUSIONS

Two studies provided evidence of a change in patient management following EUS for staging esophageal cancer, a higher level of evidence for a clinical benefit than can be obtained from accuracy studies alone. This evidence contributed to a recommendation for public funding of EUS in staging esophageal cancer in Australia.

Prospective pilot evaluation of a new needle prototype for endoscopic ultrasonography-guided fine-needle aspiration: comparison of cytology and histology yield

OBJECTIVES

Endoscopic ultrasonography (EUS) with the adjunct of EUS-guided fine needle aspiration has become an important diagnostic modality in gastroenterologic oncology. EUS-guided fine needle aspiration mainly relies on cytology; data are scarce that compare cytology and histology. While testing a 22-gauge prototype needle, we prospectively compared the yield for both.

METHODS

Forty-two consecutive patients (27 male, 15 female; mean age 59.2 years, range: 17-90 years) were included. In each patient we aimed to make two needle passes, and if the material acquired appeared insufficient macroscopically (no in-room cytopathology was available), further passes were done. The material was sent for cytological and histological assessment.

RESULTS

A median number of two passes (range: 2-3) were uneventfully performed for pancreatic lesions (n=30), mediastinal and other lymph nodes/masses (n=8) and various other lesions (n=4) and yielded adequate material for cytology, histology or at least one of the two investigations in 62, 67 and 74% of patients, respectively. No false positive results were found (specificity 100%). Sensitivities were 58.6 and 65.5%, respectively, for cytology and histology alone; combined assessment increased sensitivity to 79.3%. When adjusted values were calculated, based only on those cases with adequate material, sensitivity was 89.5% for cytology and 85.7% for histology, and increased to 100% with combined assessment.

CONCLUSION

The new needle achieves sensitivities similar to those previously reported with no significant differences in sensitivity between cytology and histology. More effective tissue acquisition methods must be sought to improve overall results.

Endoscopic ultrasound with conventional probe and miniprobe in preoperative staging of esophageal cancer

BACKGROUND

Using an endoscopic ultrasound (EUS) miniprobe, even highly stenotic esophageal cancers precluding the passage of a conventional probe can be examined without prior dilatation.

OBJECTIVE

To assess: (1) staging accuracy of conventional EUS probe and miniprobe, (2) variables influencing staging accuracy, (3) endoscopic features predicting tumor stage.

METHODS

Ninety-seven consecutive patients with esophageal cancer undergoing complete surgical resection were included. Preoperative EUS was performed using a conventional probe in nonstenotic tumors and a miniprobe in stenotic tumors. Accuracy of EUS for T and N stages was compared to pathohistological staging.

RESULTS

Overall EUS staging accuracy was 73.2% for T stage and 74.2% for N stage. It was similar for the miniprobe used in stenotic tumors vs the conventional probe used in nonstenotic tumors. Based on EUS, 84.5% of the patients would have been assigned to the appropriate therapy protocol (primary surgery vs neoadjuvant therapy). Endoscopic tumor features had no influence on staging accuracy. Tumor length >5 cm predicted advanced T and nodal positive stages.

CONCLUSIONS

The miniprobe allows adequate EUS staging of stenotic esophageal tumors precluding the passage of a conventional probe. Therefore, dilatation therapy of stenotic cancers to conduct conventional EUS should be avoided.

Current utilization and performance status of endoscopic ultrasound in a community hospital

OBJECTIVE

Endoscopic ultrasound (EUS) is an essential tool for cancer staging and investigating gastrointestinal diseases. Although it is not a widespread skill, as its expanded indications became much more advanced so did its popularity and hospital acceptance. We aimed to study the utilization and indications of upper EUS in a Hong Kong community hospital. The secondary aim was to assess our accuracy in staging of esophageal and gastric cancer and in evaluating submucosal tumors.

METHODS

All patients who had undergone upper EUS in Tuen Mun Hospital from January 2002 to December 2006 were recruited. Their background data, indications, radiological investigations, upper endoscopy and operation records and histopathologic results were retrieved for analysis. The accuracy of EUS in esophageal cancer staging, gastric cancer staging and evaluating submucosal tumors was assessed by comparing surgical and histopathologic findings.

RESULTS

A total of 645 upper EUS examinations were performed and there has been a steady increase in EUS utilization in our hospital. The most common indications were evaluating submucosal tumors and staging esophageal and gastric cancer. The accuracy of T and N staging of esophageal cancer was 71.2 and 79.7%, respectively and for gastric cancer was 64.0 and 74.7%, respectively. Endoscopic ultrasound was 70% accurate in identifying lesions arising from the submucosal layer and 100% accurate in identifying lesions from the muscularis propria.

CONCLUSION

Endoscopic ultrasound is an accurate method and its demand is increasing. The performance in a community hospital can be further improved and its utilization should expand to other indications.

Satisfaction of the referring physician: a quality control study focusing on EUS

INTRODUCTION

Utilization of endoscopic ultrasonography (EUS) is becoming more widespread. Largely in control of use of EUS, as a primary consumer of EUS, are the physicians who refer patients. This quality control study aimed to uncover remedial impediments to ideal utilization of EUS.

METHODS

Two thousand patient EUS reports, all by one endoscopist, were screened. One hundred forty referring physicians were identified. One hundred of these physicians completed extensive feedback survey questionnaires.

RESULTS

Overall satisfaction with EUS procedures was generally high. The level of satisfaction was comparable to satisfaction with gastroscopy procedures, both being significantly higher than for endoscopic retrograde cholongio-pancreatography. Sixty-nine percent of the physicians indicated their desire for more information regarding EUS, this being significantly higher among residents (vs. specialists). The open access system in current practice was seen as acceptable by less than half of physicians, both from the community and from within the hospital. Waiting time for EUS procedures and for biopsy results were rated as acceptable within the hospital, but more often as too long for outpatients.

CONCLUSIONS

Overall satisfaction with EUS procedures is high. More information should be brought to the referring physicians, in print and lectures. Improving communication and interacting with endoscopist-initiated feedback led to improved feelings of teamwork, uncovered remedial weak points in the EUS service, and was thus found to be valuable.

Endosonography- vs. endoscopic retrograde cholangiopancreatography-based strategies in the evaluation of suspected common bile duct stones in patients with normal transabdominal imaging

BACKGROUND

Endosonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are highly accurate techniques for evaluating common bile duct stones.

AIM

To compare the clinical impact and costs of EUS- and ERCP-based strategies for evaluating patients with suspected common bile duct stones but normal transabdominal imaging.

METHODS

The costs of EUS- vs. ERCP-based strategies were compared in patients with suspected acute biliary obstruction from common bile duct stones but normal transabdominal imaging.

RESULTS

Over a 15-month period, 110 patients were recruited. EUS detected a common bile duct lesion in 73% (common bile duct stones: 68%; pancreatic cancer: 2%; ampulla tumour: 2%; cholangiocarcinoma: 1%). The sensitivity, specificity, positive predictive value and negative predictive value of EUS were 98%, 100%, 100% and 93%, respectively. EUS prevented 30% unnecessary ERCP. The mean difference in cost per patient between EUS- and ERCP-based strategies was US$166. When stratified according to clinical indications, an EUS-based strategy was costlier only in suspected biliary sepsis. Costs were similar when the indications were cholestatic jaundice, acute pancreatitis and cholestasis.

CONCLUSION

EUS prior to biliary interventions in patients with suspected common bile duct stones prevented unnecessary ERCP. It allowed a definitive diagnosis to be made prior to more invasive procedures.

Impact of endoscopic ultrasonography (EUS) on surgical decision-making in upper gastrointestinal tract cancer: an international multicenter study

BACKGROUND

Endoscopic ultrasonography (EUS) is an integrated part of the pretherapeutic evaluation program for patients with upper gastrointestinal (GI) tract cancer. Whether the clinical impact of EUS differs between surgeons from different countries is unknown. The same applies to the potential clinical influence of EUS misinterpretations. The aim of this study was to evaluate the interobserver agreement on predefined treatment strategies between surgeons from four different countries, with and without EUS, and to evaluate the clinical consequences of EUS misinterpretations.

METHODS

One hundred patients with upper GI tract cancer were randomly selected from all upper GI tract cancer patients treated at Odense University Hospital between 1997 and 2000. Based on patient records and EUS database results, a case story was created with and without the EUS result for each patient. Four surgeons were asked to select the relevant treatment strategy in each case, at first without knowledge of the EUS and thereafter with the EUS result available. Interobserver agreement and impact of EUS misinterpretations were evaluated using the actual final treatment of each patient as reference.

RESULTS

Three of four or all four surgeons agreed on the same treatment strategy for nearly 60% of the patients with and without the EUS results. Treatment decisions were changed in 34% based on the EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%). Interobserver agreement was relatively low, but overall EUS increased kappa values from 0.16 ("poor") to 0.33 ("fair"), thus indicating increased overall agreement after the EUS results were available. EUS conclusion regarding stage or resectability was wrong in 17% of the cases, but only one serious event would have been the clinical result of EUS misinterpretations.

CONCLUSION

Despite being used in different ways by different surgeons, EUS did change patient management in one third of the cases. The impact of EUS misinterpretations seemed very low, and this study confirmed one of the strongest clinical possibilities of EUS, i.e., the ability to detect nonresectable cases. EUS is an important imaging modality for oncosurgeons from different countries.

Multicentre retrospective study on endoscopic ultrasound complications

BACKGROUND

Endoscopic ultrasonography, both conventional and interventional, has been used increasingly during the past 20 years and is deemed a safe technique. Its complication rate, however, has been studied to only a limited extent. This multicentre investigation sought to establish the complication rate for a large number of endoscopic ultrasonography procedures.

METHODS

By means of a questionnaire, we collected data from six centres on the number of endoscopic ultrasonography examinations performed and divided them into conventional and interventional examinations of the upper and lower gastrointestinal tract. Information was obtained on technical modalities such as instruments and sedation and, for interventional endoscopic ultrasonography, indications, pre-procedural exams and technical details (needle calibre, number of passes) had to be specified. Complications were classified as mild, moderate, severe or fatal and their onset as immediate, early or late. Variables that entered into the analysis of complication rate included type of endoscopic ultrasonography instrument used, type and site of lesion biopsied, number of needle passes and operator experience.

RESULTS

Eleven thousand five hundred thirty nine endoscopic ultrasonographic procedures were reported, of which 10,731 were conventional and 808 interventional. No deaths occurred; there were 14 (0.12%) complications, 5 (0.046%) of them following conventional endoscopic ultrasonography and 9 (1.11%) after interventional endoscopic ultrasonography. Seven complications were mild, four moderate and three severe.

CONCLUSIONS

Both conventional and interventional endoscopic ultrasonography were confirmed to be acceptably safe techniques.

Gastric cancer: standards for the 21st century

Although the incidence of gastric cancer has been decreasing in the United States, it remains a leading cause of cancer death in the world, only lung cancer causes more deaths worldwide. The combination of relatively low prevalence, lack of pathognomonic symptoms, and lack of defined risk factors are associated with a delay in diagnosis leading to a dismal prognosis. For localized disease, surgery remains a cornerstone of treatment but much controversy remains regarding optimal peri-operative therapy. For advanced disease, several new agents and new combination chemotherapies have offered encouraging results. This paper seeks to review the major topics surrounding gastric cancer and cover the results of recently reported and ongoing trials.

Does the Advent of Endoscopic Ultrasound (EUS) Sound the Death Knell for Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has been the premier diagnostic and therapeutic endoscopic procedure in the management of pancreatic and biliary diseases (PBD). The use of endoscopic ultrasound (EUS), including EUS-guided fine needle aspiration (FNA), of pancreatic and biliary tumours has become more widely available in the last decade and has gradually replaced diagnostic ERCP. Together with EUS, other imaging modalities like magnetic resonance cholangiopancreatography (MRCP) have resulted in a decrease in the number of ERCPs. With the advent of interventional EUS, ERCP is at risk of being completely eclipsed. Methods: A search of all relevant articles on EUS and ERCP from Medline and peer-reviewed journals. Results: This review article examines the exact place of ERCP and EUS and their relative contributions in the management algorithm of PBD. Conclusion: Although diagnostic EUS, including EUS-guided FNA, is well established in the evaluation of PBD, interventional EUS is still in its infancy and its true potential is unknown. Therefore, therapeutic ERCP still has a vital, albeit smaller role to play in the treatment of pancreatic and biliary diseases. Key words: Biliary diseases, Endoscopic retrograde cholangiopancreatography, Endosonography, Pancreatic

Practice patterns and attitudes toward the role of endoscopic ultrasound in staging of gastrointestinal malignancies: a survey of physicians and surgeons

BACKGROUND AND AIMS

It is unknown how physician specialties other than gastroenterologists that manage gastrointestinal (GI) malignancies utilize endoscopic ultrasound (EUS) in their practices. The aim of this study was to (i) assess the proportion of gastroenterologists, oncologists, and surgeons that utilize EUS for staging of GI malignancies; (ii) assess the general availability of EUS; and (iii) determine which factors are associated with the use and availability of EUS.

METHODS

A self-administered questionnaire was mailed out to 1,200 randomly selected gastroenterologists, oncologists, and surgeons throughout the United States.

RESULTS

The data was analyzed from 521 (43%) responses. There were 60% respondents who had EUS available within their practices. There was greater availability of EUS within the practices of surgeons (81%; p < 0.001), within academic practices (87%; p= < 0.001), and in practices that serve a population >500,000 (p < 0.001). The majority of respondents (71%) utilized EUS in their practices. There was a similar utilization of EUS across specialties (p= NS). There was greater utilization of EUS in academic centers (82%; p < 0.001), in practices that served a community of >500,000 (p= 0.003), and among respondents who had been in practice for less than 5 yr (p= 0.005). Employing logistic regression models for utilization of EUS, lesser number of years in practice, and availability of EUS were found to be the only significant predictors of utilization.

CONCLUSIONS

The majority of practitioners utilized EUS in management of GI malignancies. There was similar utilization of EUS across specialties. EUS is available to the majority of practitioners who manage GI malignancies.

Endoscopic ultrasound-guided fine-needle aspiration cytology for diagnosis above and below the diaphragm

Endosonography ultrasound (EUS) is a minimally invasive technology using a high-frequency ultrasound transducer that is incorporated into the tip of a conventional endoscope. This technique permits high-resolution imaging of the gastrointestinal wall and structures in its vicinity, as well as real-time endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). This is a review of the literature on EUS-guided FNA of the mediastinal and abdominal lymph nodes, the pancreas, intramural gastrointestinal masses, and other miscellaneous organs and body cavities. EUS-guided FNA is a recently developed procedure that has established itself as a safe, highly accurate, and clinically useful modality.

Prospective study of the clinical impact of EUS

BACKGROUND

Studies on the clinical impact of EUS are lacking. The aim of this study was to examine the impact of EUS on the management plans by referring doctors and patient outcomes.

METHODS

Consecutive patients undergoing EUS between August 2002 and June 2004 were prospectively studied. Referring doctors were given a pre-EUS questionnaire that asked about provisional diagnosis and management plan. A post-EUS questionnaire was sent 6 weeks after the procedure.

RESULTS

A total of 330 patients were examined, and completed questionnaires were received in 70%. EUS-guided FNA was performed in 69 (30%) patients. EUS resulted in a change in diagnosis and management in 26% and 48% of cases, respectively. Thirty-nine of the latter patients (33%) avoided unnecessary surgery. In 50% of cases, additional investigations were avoided. Doctors reported EUS as very or moderately useful in 210 patients (91%). Doctors of 223 patients (97%) reported that they would use EUS again.

CONCLUSIONS

The use of EUS had a significant clinical impact on patients. EUS resulted in a change of diagnosis in a fourth of patients and a change in management in half of patients studied.

Role of endoscopic ultrasonography in the staging and follow-up of esophageal cancer

PURPOSE

To evaluate the role of endoscopic ultrasonography (EUS) in the initial staging and follow-up of esophageal cancer on the basis of a review of the published literature.

METHODS

Articles published from 1985 to 2005 were searched and reviewed using the following keywords: "esophageal cancer staging," "endoscopic ultrasound," and "endoscopic ultrasonography."

RESULTS

For initial anatomic staging, EUS results have consistently shown more than 80% accuracy compared with surgical pathology for depth of tumor invasion (T). Accuracy increased with higher stage, and was >90% for T3 cancer. EUS results have shown accuracy in the range of 75% for initial staging of regional lymph nodes (N). EUS has been invariably more accurate than computed tomography for T and N staging. EUS is limited for staging distant metastases (M), and therefore EUS is usually performed after a body imaging modality such as computed tomography or positron emission tomography. Pathologic staging can be achieved at EUS using fine-needle aspiration (FNA) to obtain cytology from suspect Ns. FNA has had greatest efficacy in confirming celiac axis lymph node metastases with more than 90% accuracy. EUS is inaccurate for staging after radiation and chemotherapy because of inability to distinguish inflammation and fibrosis from residual cancer, but a more than 50% decrease in tumor cross-sectional area or diameter has been found to correlate with treatment response.

CONCLUSION

EUS has a central role in the initial anatomic staging of esophageal cancer because of its high accuracy in determining the extent of locoregional disease. EUS is inaccurate for staging after radiation therapy and chemotherapy, but can be useful in assessing treatment response.

A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses

BACKGROUND

The purpose of this study is to prospectively evaluate the performance characteristics of endoscopy and EUS in the diagnosis of GI subepithelial masses.

METHODS

A total of 100 consecutive patients referred for the evaluation of a suspected GI subepithelial lesion were prospectively studied with endoscopy followed by EUS. Size, color, mobility, location (intramural or extramural), consistency (solid, cystic, or vascular), and presumptive diagnosis were recorded at the time of endoscopy. EUS then was performed, and size, echogenicity, location, and presumptive diagnosis were determined.

RESULTS

A total of 100 subepithelial lesions were evaluated. Endoscopy had 98% sensitivity and 64% specificity in identifying intramural lesions. Size measurement by endoscopy correlated with size measurement by EUS (r = 0.88). Histology was obtained in 23 cases, with the presumptive EUS diagnosis correct in only 48% of cases. Most incorrect EUS diagnoses occurred with hypoechoic 3rd and 4th layer masses.

CONCLUSIONS

Endoscopy has high sensitivity but low specificity in identifying the location (intramural or extramural) of subepithelial lesions. In addition, EUS imaging alone is insufficient to accurately diagnose 3rd and 4th layer hypoechoic masses, and histologic confirmation should be obtained whenever possible.

Endoscopic approach to gastrointestinal stromal tumors

Unrevealing CT scans and ambiguous surveillance endoscopies fuel rising frustration for patient and physician. Several recent developments have added considerably to our understanding of submucosal masses and the stromal cell tumors often lurking within them.

Present and future of endoscopic ultrasonography

Endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle aspiration are well-established techniques, encompassing a variety of diagnostic and therapeutic applications. Along with traditional indications that constitute everyday clinical practice in all endoscopic ultrasonography centres, new indications are emerging that resemble the continuing research carried on in this field. Some of these are innovative applications, developed by highly experienced endosonographers and with a putative role for clinical practice in the near future. Others are merely experimental applications, carried out on in animal models or in highly selected groups of patients, opening up new fascinating areas of research but not for imminent introduction in clinical practice. The purpose of this review, after summarising the present indications of endoscopic ultrasonography, is to focus on the future applications and try to establish their possible advent, either in the near or in the far future.

Clinical impact of endoscopic ultrasonography on the management of malignancies

BACKGROUND & AIMS

There are limited data evaluating the clinical impact of endoscopic ultrasonography (EUS). We assessed the impact of EUS on management of known or suspected malignancies.

METHODS

Physicians requesting EUS were contacted before the examination and asked: "How would you manage this patient if EUS were not available?" Pre-EUS responses were recorded on standardized forms, and compared with management recommendations as determined by the same requesting physician after EUS. Endosonographers performing the study were blinded to the pre-EUS responses.

RESULTS

Responses were obtained from requesting physicians before and after EUS in 90 patients. Requesting physicians were composed of surgeons (33%), non-EUS-performing gastroenterologists (58%), oncologists (3%), internists (4%), and a pulmonologist (1%). After EUS, referring clinicians altered management plans in 46 of 90 patients (51%). By anatomic site, management changes occurred in 12 of 22 patients (56%) undergoing esophageal EUS, 9 of 15 (60%) undergoing gastric EUS, 21 of 43 (49%) undergoing pancreatic EUS, and 4 of 10 (40%) undergoing rectal EUS. There were no significant differences in the frequency of post-EUS management changes with respect to examination site (P = .76). EUS fine-needle aspiration (FNA) altered management in 9 of 20 (45%) patients. Management changes involved less complex or decreased risk-associated approaches in the majority (70%), and included 14 of 50 (28%) patients in whom surgical procedures were no longer planned.

CONCLUSIONS

Based on EUS examination findings, clinicians requesting EUS alter patient management in one half of cases, and more often pursue a less-complicated approach. EUS substantially impacts clinical care, and should be used in appropriate settings to guide patient management.

Therapeutic options for esophageal cancer

Options for the treatment of esophageal cancer used to be very limited, with surgical resection and radiotherapy methods aimed at both cure or palliation, and, in those unfortunate patients with severe dysphagia, intubation with a plastic prosthesis to restore esophageal luminal patency. Progress in the management of this cancer in the past two decades includes refinement in surgical techniques and perioperative care, better radiological staging methods, enhanced means of planning and delivering radiotherapy, multimodality treatments, and better designs in esophageal prosthesis. For individual patients, a stage-directed therapeutic plan can be used. Long-term survival, however, remains suboptimal for this deadly disease. The current review presents an overview of the commonly employed therapeutic options for esophageal cancer at the beginning of the 21st century.

Effect of endoscopic ultrasonography on the management of 100 consecutive patients with oesophageal and junctional carcinoma

BACKGROUND

Endoscopic ultrasonography (EUS) offers very accurate tumour and node staging information for oesophagogastric cancer. The aim was to determine whether the addition of EUS directly influenced the definitive management plan for individual patients.

METHODS

Personal and staging information from 100 consecutive patients with carcinoma of the oesophagus or oesophagogastric junction were summarized and blinded. Three consultant oesophagogastric surgeons independently made a management decision for each patient, in the presence and absence of the EUS data. All scored their perceived value of the EUS staging data for each patient.

RESULTS

EUS was deemed useful in 63-87 per cent of patients and its addition resulted in an increased number of concordant management plans (from 53 to 62 per cent), and increased agreement between surgeons. The greatest change in concordant management was an increased referral of patients for non-surgical palliation.

CONCLUSION

The addition of EUS to the staging of patients with oesophageal and oesophagogastric junction cancer significantly altered the management strategy for some of these patients.

ENDOSCOPIC ULTRASOUND INSTRUMENTATION, APPLICATIONS IN HUMANS, AND POTENTIAL VETERINARY APPLICATIONS

Endoluminal scanning under endoscopic guidance, or endoscopic ultrasonography (EUS), has become the most significant advance for imaging the gastrointestinal (GI) tract wall and contiguous organs in the past 20 years. It was originally designed to overcome the limitations in humans to imaging the abdominal organs transabdominally, such as large penetration depths and GI air. This imaging modality provides detailed images of pathological processes both within and outside of the GI wall since a high-frequency transducer can be brought into close proximity with the target regions. It has found most success in humans for the staging of lung, gastric, and esophageal cancer, the detection of both lymphatic and hepatic metastases, and diagnosis of pancreatitis and pancreatic cancer, as well as achieving an important role in interventional and therapeutic procedures. The EUS examination can be performed to examine both the thorax and abdomen in animals when both conventional transthoracic or transabdominal ultrasound are inadequate due to intervening air, bone, large penetration depths, or obesity. The echoendoscope is similar to a conventional endoscope but has an ultrasound transducer at its tip. Both radial and linear multifrequency scanners are available. Linear scanners allow fine-needle aspiration (FNA) of the bowel wall or extraluminal structures. Transducer coupling is either by direct mucosal contact or by inflation of a water-filled balloon surrounding the transducer. Current thoracic applications for EUS in veterinary medicine include examination of the mediastinum, bronchial lymph nodes, esophagus, and pulmonary lesions as well as FNA of pulmonary masses. Abdominal applications include examination of both pancreatic limbs and the liver, including portosystemic shunts, detection of lymphadenomegaly, and examination of the gastric wall, duodenum, and jejunum. Other potential applications in dogs and cats include tumor staging and intrapelvic ultrasound.

Computer-assisted analysis of lymph nodes detected by EUS in patients with esophageal carcinoma

BACKGROUND

EUS determination of lymph nodal spread of intestinal cancer based on imaging alone is problematic. A noninvasive, reliable means of determining tumor spread to lymph nodes is desirable. This study investigated the feasibility of a computer-assisted evaluation of lymph nodes detected by EUS in patients with esophageal carcinoma.

METHODS

Images were obtained during EUS of esophageal lesions and correlated with histopathologic findings after esophagectomy. Sonographic features of echogenicity, whole-node heterogeneity, and regional variability were assessed by computerized image analysis in patients with benign versus malignant lymphadenopathy.

RESULTS

Malignant lymph nodes were hypoechoic compared with benign lymph nodes (p < 0.04). Whole lymph node heterogeneity was increased in malignant lymph nodes (p < 0.004). Regional variability was greater for benign lymph nodes.

CONCLUSIONS

These data support the feasibility of a computer-assisted system for analysis of lymph node metastasis in patients with esophageal carcinoma. Further refinements of such a system could increase the accuracy of EUS staging of tumors.

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

Potential impact of preoperative EUS on esophageal cancer management and cost

BACKGROUND

The purpose of this study was to determine the relative proportions of esophageal cancer stages in a group of patients referred for preoperative EUS, to determine the proportions of EUS stage 1 and 4 tumors that would not be treated with combined modality therapy, and to estimate the impact of the EUS diagnosis of these stages on costs.

METHODS

A large national endoscopic database was reviewed retrospectively to identify cases of esophageal cancer in which there was a referral for preoperative staging with EUS. Data were analyzed as to demographics, histology and tumor stage by EUS according to the American Joint Commission for Cancer tumor node metastasis classification system for esophageal cancer. Cost estimates were based on Medicare reimbursement rates and published figures.

RESULTS

Of 188 EUS procedures done for preoperative staging of esophageal cancer (82% men, mean age 66.5 years), the histopathologic types of cancer were: adenocarcinoma, 107; squamous cell carcinoma, 39; and unknown histology, 42. Numbers and proportions of patients by American Joint Commission for Cancer group stage based on 162 procedures for which complete staging information was available are as follows: Stage I, 23 patients (14%); Stage II, 51 (31%); Stage III, 69 (43%); and Stage IV, 19 (12%). Therefore, for every 100 patients staged before surgery with EUS (cost $63,420), 14 patients with Stage I disease would be spared neoadjuvant chemoradiotherapy (saving $122,192) and 12 patients with Stage IV cancer would be spared surgery (saving $285,600) for an average cost savings of $3443 per patient.

CONCLUSION

Preoperative staging of esophageal cancer with EUS identifies a significant proportion of patients (26% in this series) with stage I and IV tumors who may be spared combined modality therapy with an associated potential for cost savings.

Upper gastrointestinal endoscopic ultrasound and its impact on patient management: 1990-2000

BACKGROUND

Endoscopic ultrasound (EUS) is a relatively new method used in the investigation and staging of upper gastrointestinal tract (UGIT) disease.

AIMS

To review practice and outcomes of EUS in an Australian university teaching hospital.

METHODS

The first part of the study was a retrospective review of indications, safety, referral patterns and technical difficulties of all EUS procedures performed at Concord Hospital, New South Wales, Australia, over a 10-year period from 1990 to 2000. The second part of the study examined the impact of EUS on the management of 225 consecutive cases, as determined by a questionnaire completed by each of the referring doctors.

RESULTS

A total of 537 EUS examinations was performed over the 10-year period. Indications for EUS included: (i) assessment of oesophageal lesions (241), (ii) assessment of gastric lesions (184) and (iii) assessment of pancreaticobiliary (112) disease. Cancer staging was performed in 46.7% of oesophageal and 31.4% of gastric cases. Sedation was achieved using intravenous midazolam (5.3+/-1.3 mg; mean +/- SD) and 52% of cases required additional intravenous pethidine (48.5+/-10.0 mg; mean +/- SD). Technical difficulties were encountered in 11% of cases and these were mainly related to nontraversable luminal stricturing. Of the 537 referrals, 48.2% were from within Central Sydney Area Health Services, and the remainder were from other Sydney hospitals, New South Wales regional centres and interstate. Of 225 questionnaires sent to referring doctors, 146 questionnaires were completed and returned for analysis. EUS aided staging of malignant disease, and confirmed or established a diagnosis in 86% of cases. The diagnostic accuracy of EUS was 76% when confirmed histologically. EUS avoided further diagnostic investigations in the majority of cases and in 25% of cases surgery was avoided. Fine-needle aspiration biopsy (FNAB) during EUS would have been useful in 30% of cases. Overall, clinical decision-making and management were changed in one-third of cases.

CONCLUSIONS

Endoscopic ultrasound is an accurate, safe and useful imaging method in UGIT disease. The increasing demand for EUS and EUS-guided FNAB suggests an expanding future for EUS in Australia.

EUS-guided fine needle aspiration of the liver: indications, yield, and safety based on an international survey of 167 cases

BACKGROUND

The liver is a common site of metastases for various malignancies. EUS-guided fine needle aspiration (EUS-FNA) of liver masses has only been reported in small series from single centers.

METHODS

A retrospective questionnaire was sent by e-mail to 130 EUS-FNA centers around the world regarding indications, complications, and findings of EUS-FNA of the liver.

RESULTS

Twenty-one centers reported 167 cases of EUS-FNA of the liver. A complication was reported in 6 (4%) of 167 cases including the following: death in 1 patient with an occluding biliary stent and biliary sepsis, bleeding (1), fever (2), and pain (2). EUS-FNA diagnosed malignancy in 23 of 26 (89%) cases after nondiagnostic fine needle aspiration under transabdominal US guidance. EUS localized an unrecognized primary tumor in 17 of 33 (52%) cases in which CT had demonstrated only liver metastases. EUS image characteristics were not predictive of malignant versus benign lesions.

CONCLUSION

EUS-guided FNA of the liver appears to be a safe procedure with a major complication rate of approximately 1%. EUS-FNA should be considered when a liver lesion is poorly accessible to US-, or CT-guided FNA should be considered when US- or CT-guided FNA fail to make a diagnosis, when a liver lesion(s) is detected (de novo) by EUS, and for investigation of possible upper GI primary tumors in the setting of liver metastases.

Subepithelial masses of the gastrointestinal tract evaluated by endoscopic ultrasonography

OBJECTIVES

To diagnose and characterize subepithelial lesions of the gastrointestinal (GI) tract using endoscopic ultrasonography (EUS) and search for markers of malignancy in stromal cell tumors.

METHODS

Fifty-four patients with suspected subepithelial lesions at endoscopy were examined using miniature ultrasound probes, integrated ultrasound endoscopes, or both. Surgical treatment was considered if a solid lesion had a maximum diameter of at least 3 cm, mixed echogenicity, or an ill-defined or irregular border.

RESULTS

EUS disclosed 37 solid lesions and ten fluid-filled structures. In seven patients, including two with protrusion from a normal spleen, no pathology could be demonstrated. Thirteen patients were operated and 41 were observed clinically with (n = 9) or without EUS (n = 32) for a median follow-up period of 36 months. Twenty-three patients had an intramural stromal cell tumor. None of these were malignant, but increased mitotic activity was found in two medium-sized resected tumors with mixed echogenicity and bleeding lesions of the endoluminal surface.

CONCLUSION

EUS can detect and characterize subepithelial masses in the GI tract. Pathologic lesions of the overlying mucosa may indicate malignant development in stromal cell tumors, but valid markers of malignant potential are still lacking.

Endoscopic ultrasonography in the diagnosis and management of suspected upper gastrointestinal submucosal tumours

BACKGROUND

'Submucosal' lesions in the upper gastrointestinal tract are often difficult to evaluate. Endoscopic ultrasonography (EUS) provides high-quality information about the nature of these lesions and may assist management. This study assessed the use of EUS in the evaluation and management of upper gastrointestinal submucosal tumours.

METHODS

Forty-four consecutive patients were referred with suspected upper gastrointestinal submucosal lesions for EUS. All examinations were performed by one of two experienced endosonographers.

RESULTS

Most patients were referred for EUS with a suspected gastrointestinal stromal tumour. The pre-EUS diagnosis did not correlate with the EUS diagnosis in 25 of 44 patients. Pathological correlation was possible in 16 patients, and the EUS diagnosis was confirmed in each case. Based on the findings at EUS, 12 patients underwent resection. Pathology confirmed the ultrasonographic findings in these patients. Follow-up EUS to monitor lesions was recommended in a further three patients.

CONCLUSION

EUS is safe and provides useful information in many patients with suspected submucosal tumours. EUS may reveal unsuspected findings and can increase physician certainty, allowing accurate diagnosis and facilitation of the management process.