A biomarker panel predicts progression of Barrett's esophagus to esophageal adenocarcinoma

Progression from Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC) is uncommon but the consequences are serious. Predictors of progression are essential to optimize resource utilization. This study assessed the utility of a promising panel of biomarkers applicable to routine paraffin embedded biopsies (FFPE) to predict progression of BE to EAC in a large population-based, nested case-control study.We utilized the Amsterdam-based ReBus nested case-control cohort. BE patients who progressed to high-grade dysplasia (HGD)/EAC (n = 130) and BE patients who never progressed (n = 130) were matched on age, sex, length of the BE segment, and duration of endoscopic surveillance. All progressors had minimum 2 years of endoscopic surveillance without HGD/EAC to exclude prevalent neoplasia. We assessed abnormal DNA content, p53, Cyclin A, and Aspergillus oryzae lectin (AOL) in FFPE sections. We performed conditional logistic regression analysis to estimate odds ratio (OR) of progression based on biomarker status.Expert LGD (OR, 8.3; 95% CI, 1.7-41.0), AOL (3 vs. 0 epithelial compartments abnormal; OR, 3.6; 95% CI, 1.2-10.6) and p53 (OR, 2.3; 95% CI, 1.2-4.6) were independently associated with neoplastic progression. Cyclin A did not predict progression and DNA ploidy analysis by image cytometry was unsuccessful in the majority of cases, both were excluded from the multivariate analysis. The multivariable biomarker model had an area under the receiver operating characteristic curve of 0.73.Expert LGD, AOL, and p53 independently predict neoplastic progression in BE patients and are applicable to routine practice. These biomarkers can aid in selecting patients for endoscopic ablation or more intensive surveillance.

Association of sporadic and familial Barrett's esophagus with breast cancer

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC). Based on striking aggregation of breast cancer and BE/EAC within families as well as shared risk factors and molecular mechanisms of carcinogenesis, we hypothesized that BE may be associated with breast cancer. Pedigree analysis of families identified prospectively at multiple academic centers as part of the Familial Barrett's Esophagus Consortium (FBEC) was reviewed and families with aggregation of BE/EAC and breast cancer are reported. Additionally, using a matched case-control study design, we compared newly diagnosed BE cases in Caucasian females with breast cancer (cases) to Caucasian females without breast cancer (controls) who had undergone upper endoscopy (EGD). Two familial pedigrees, meeting a stringent inclusion criterion, manifested familial aggregation of BE/EAC and breast cancer in an autosomal dominant inheritance pattern with incomplete penetrance. From January 2008 to October 2016, 2812 breast cancer patient charts were identified, of which 213 were Caucasian females who underwent EGD. Six of 213 (2.82%) patients with breast cancer had pathology-confirmed BE, compared to 1 of 241 (0.41%) controls (P-value < 0.05). Selected families with BE/EAC show segregation of breast cancer. A breast cancer diagnosis is marginally associated with BE. We postulate a common susceptibility between BE/EAC and breast cancer.

Lymph node characterization in vivo using endoscopic ultrasound spectrum analysis with electronic array echo endoscopes

Our purpose was to demonstrate the use of radiofrequency spectral analysis to distinguish between benign and malignant lymph nodes with data obtained using electronic array echo endoscopes, as we have done previously using mechanical echo endoscopes. In a prospective study, images were obtained from eight patients with benign-appearing lymph nodes and 11 with malignant lymph nodes, as verified by fine-needle aspiration. Midband fit, slope, intercept, correlation coefficient, and root-mean-square (RMS) deviation from a linear regression of the calibrated power spectra were determined and compared between the groups. Significant differences were observable for mean midband fit, intercept, and RMS deviation (t test P < 0.05). For benign (n = 16) vs. malignant (n = 12) lymph nodes, midband fit and RMS deviation provided classification with 89 % accuracy and area under receiver operating characteristic (ROC) curve of 0.95 based on linear discriminant analysis. We concluded that the mean spectral parameters of the backscattered signals from electronic array echo endoscopy can provide a noninvasive method to quantitatively discriminate between benign and malignant lymph nodes.

Endoscopic full-thickness resection of gastric tumors using a novel grasp-and-snare technique: feasibility in ex vivo and in vivo porcine models

BACKGROUND AND STUDY AIMS

Endoscopic full-thickness resection (EFTR) is a less-invasive method of en bloc removal of gastrointestinal tract tumors. The aim of this study was to evaluate the feasibility of a grasp-and-snare EFTR technique using a novel tissue-lifting device that provides more secure tissue anchoring and manipulation.

METHODS

EFTR of normal gastric tissue and model stomach tumors was performed using a double-channel therapeutic endoscope with a prototype tissue-lifting device through one channel and a prototype hexagonal snare through the other. The lifting device was advanced through the open snare and anchored to the gastric wall immediately adjacent the model tumor. The tissue-lifting device was then partially retracted into the endoscope, causing the target tissue, including tumor, to evert into the gastric lumen. The open snare was then placed distal to the tumor around uninvolved gastric tissue. Resection was performed with a blended electrosurgical current through the snare. In the live pigs, EFTR was followed by laparotomy to asses for complications.

RESULTS

24 EFTRs were performed -- 14 in explanted stomachs and 10 in live pigs. In total, 23/24 resections resulted in full-thickness gastric defects. Resection specimens measured up to 5.0 cm when stretched and pinned on a histology stage. Gross margins were negative in 17/20 model tumor resections. Two resections were complicated by gastric mural bleeding. There was no evidence of adjacent organ injury.

CONCLUSIONS

EFTR of gastric tumors using the grasp-and-snare technique is feasible in pigs. This technique is advantageous in that eversion of the gastric wall avoids injury to external organs, continuous luminal insufflation is not required, and the involved techniques are familiar to endoscopists. Additional research is necessary to further evaluate safety and reliable closure.

Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator

BACKGROUND

The NDO Plicator is a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD) by approximation of tissues together with a double-pledgeted U-stitch. It was theorized that this device may facilitate transgastric natural orifice translumenal endoscopic surgery (NOTES) because closure of the transgastric defect remains a key component for advancement of this new technology.

METHODS

A standardized 12-mm gastrotomy was created endoscopically in four pigs using a combination of needle-knife cautery and balloon dilation. As the endoscope was removed, a Savary soft-tipped wire was introduced into the stomach, and the NDO Plicator was subsequently advanced over the wire. Each defect was identified, and the device was positioned. If necessary, the Plicator's tissue grasper was used to hold the superior aspect of the gastrotomy and bring the opposed borders of the defect within the jaws of the device. The device was fired three times, leaving three pledgeted suture bundles to close the gastric defect. After closure, each animal was explored, and the integrity of the closure was assessed. The animals underwent in vivo contrast fluoroscopy and ex vivo burst pressure testing studies for assessment of leakage at the closure site.

RESULTS

The first animal was used to test feasibility, refine techniques, and develop a standard procedure. All of the next three animals studied showed complete sealing of the gastrotomy site without evidence of contrast extravasation on multiplanar fluoroscopic imaging. Each stomach was excised, submerged in water, and subjected to a pressurized air leak test. No leaks were noted until pressures exceeded 55 mmHg.

CONCLUSION

This study supports the use of the NDO Plicator for closure of standardized gastric defects in a porcine model. In addition to closing NOTES gastrotomies, the NDO Plicator may be a particularly useful tool for obtaining complete closure of gastric perforations and anastomotic leaks, and for performing stomal reduction after gastric bypass procedures. The mechanical properties of a closure are not the only factor determining whether a leak will develop. Tissue opposition, ischemia, and tension are important factors that are not easily or reliably measured. The physiologic relevance of gastric bursting pressure is not known. Therefore, corollary animal studies with longer-term evaluation are necessary before research proceeds to clinical trials.

A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) provides surgical access to the peritoneal cavity without skin incisions. The NOTES procedure requires pneumoperitoneum for visualization and manipulation of abdominal organs, similar to laparoscopy. Accurate measurement of the pneumoperitoneum pressure is essential to avoid potentially deleterious effects of intraabdominal compartment syndrome. A reliable method for monitoring pneumoperitoneum pressures during NOTES has not been identified. This study evaluated several methods of monitoring intraabdominal pressures with a standard gastroscope during NOTES.

METHODS

Four female pigs (25 kg) were sedated, and a single-channel gastroscope was passed transgastrically into the peritoneal cavity. Pneumoperitoneum was achieved via a pressure insufflator through a percutaneous, intraperitoneal 14-gauge catheter. Three other pressures were recorded via separate catheters. First, a 14-gauge percutaneous catheter passed intraperitoneally measured true intraabdominal pressure. Second, a 14-gauge tube attached to the endoscope was used to measure endoscope tip pressure. The third pressure transducer was connected directly to the accessory channel of the endoscope. The abdomen was insufflated to a range of pressures (10-30 mmHg), and simultaneous pressures were recorded from all three pressure sensors.

RESULTS

Pressure correlation curves were developed for all animals across all intraperitoneal pressures (mean error, -4.25 to -1 mmHg). Endoscope tip pressures correlated with biopsy channel pressures (R2 = 0.99). Biopsy channel and endoscope tip pressures fit a least-squares linear model to predict actual intraabdominal pressure (R = 0.99 for both). Both scope tip and biopsy channel port pressures were strongly correlative with true intraabdominal pressures (R2 = 0.98 and R2 = 0.99, respectively).

CONCLUSION

This study demonstrates that monitoring pressure through an endoscope is reliable and predictive of true intraabdominal pressure. Gastroscope pressure monitoring is a useful adjunct to NOTES. Future NOTES procedures should incorporate continuous intraabdominal pressure monitoring to avoid the potentially deleterious effects of pneumoperitoneum during NOTES. This can be achieved by the integration of pressure-monitoring capabilities into gastroscopes.

Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients

BACKGROUND

Up to 50% of the patients in the intensive care unit (ICU) require mechanical ventilation, with 20% requiring the use of a ventilator for more than 7 days. More than 40% of this time is spent weaning the patient from mechanical ventilation. Failure to wean from mechanical ventilation can in part be attributable to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics, which are normally improved by maintaining a more natural negative chest pressure. The authors have previously shown that laparoscopic implantation of a diaphragm pacing system benefits selected patients. They now propose that an acute ventilator assist with interventional neurostimulation of the diaphragm in the ICU is feasible and could facilitate the weaning of ICU patients from mechanical ventilation. Natural orifice transluminal endoscopic surgery (NOTES) has the potential to expand the benefits of the diaphragm pacing system to this acute patient population by allowing it to be performed at the bedside similarly to insertion of the common gastrostomy tube. This study evaluates the feasibility of this approach in a porcine model.

METHODS

Pigs were anesthetized, and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilation. The diaphragm was mapped using a novel endoscopic electrostimulation catheter to locate the motor point (where stimulation provides complete contraction of the diaphragm). An intramuscular electrode then was placed at the motor point with a percutaneous needle. The gastrotomy was managed with a gastrostomy tube.

RESULTS

Four pigs were studied, and the endoscopic mapping instrument was able to map the diaphragm to identify the motor point. In one animal, a percutaneous electrode was placed into the motor point under transgastric endoscopic visualization, and the diaphragm could be paced in conjunction with mechanical ventilation.

CONCLUSIONS

These animal studies demonstrate the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.

The No Endosonographic Detection of Tumor (NEST) Study: a case series of pancreatic cancers missed on endoscopic ultrasonography

BACKGROUND AND STUDY AIMS

The purpose of this study was to identify possible associated factors that may have contributed to failure to detect a pancreatic neoplasm during endoscopic ultrasound (EUS) examinations by experienced endosonographers.

PATIENTS AND METHODS

A multicenter retrospective study was organized, and 20 cases of pancreatic neoplasms missed by nine experienced endosonographers were identified. Careful analysis of each case was carried out to identify the factors that might have led to the missed diagnosis on EUS.

RESULTS

Twelve patients with a missed pancreatic neoplasm had EUS features of chronic pancreatitis. Other factors that might have increased the likelihood of a false-negative EUS examination included a diffusely infiltrating carcinoma (n = 3), a prominent ventral/dorsal split (n = 2), and a recent episode (within the previous 4 weeks) of acute pancreatitis (n = 1). Five patients with a negative initial EUS underwent a follow-up EUS after 2-3 months, with a pancreatic mass being found in all cases. Three patients had a diffusely infiltrating pancreatic adenocarcinoma.

CONCLUSIONS

EUS is not a foolproof method of detecting a pancreatic neoplasm. Possible associated factors that may increase the likelihood of a false-negative EUS examination include chronic pancreatitis, a diffusely infiltrating carcinoma, a prominent ventral/dorsal split and a recent episode (< 4 weeks) of acute pancreatitis. If there is a high clinical suspicion of pancreatic neoplasm, if EUS and other imaging methods are negative, and if the patient does not undergo surgery, this study suggests that a repeat EUS after 2-3 months may be useful for detecting an occult pancreatic neoplasm.

Endoscopic ultrasonography

Increasing research related to endoscopic ultrasonography is published every year. A welcome trend towards outcomes-oriented research, evaluating the impact of endoscopic ultrasonography on patient management, is continuing. As experience regarding the safety and efficacy of endosonography-guided fine-needle aspiration in different clinical settings accumulates, this procedure is rapidly becoming a key component of endoscopic ultrasonography. Although promising developments in the fields of guided tissue sampling and image acquisition and analysis are being reported, innovative technical ideas need to be incorporated into the existing endoscopic ultrasound technology to take it to the next level of applications, such as endosurgery.

Demographic and phenotypic features of 70 families segregating Barrett's oesophagus and oesophageal adenocarcinoma

BACKGROUND

Based on reported familial patterns, inheritance of a predisposition of developing Barrett's oesesophagus (BO) and oesophageal adenocarcinoma (OAC) likely follows an autosomal dominant model of most inherited cancer syndromes. oesophagus (BO) and oesophageal adenocarcinoma (OAC) likely follows an autosomal dominant model of most inherited cancer syndromes.

AIMS

We analysed the phenotypic features of 70 familial BO/OAC families accrued for the purpose of initiating a linkage study to search for genes that contribute to susceptibility for BO/OAC.

METHODS

Families with young or familial BO/OAC were recruited from participating institutions and self-referral from advertisement.

RESULTS

A total of 70 families (173 affected and 784 unaffected individuals) were recruited into this study. Mean ages of diagnosis of BO and OAC among males were 50.6 and 57.4 years, respectively; among females, 52.1 and 63.5 years, respectively. The standardised incidence ratio (SIR) of cancers other than OAC or oesophagogastric junctional adenocarcinoma (OGJAC), among probands was 0.71. Seventy one percent of the pedigrees have "typical" structures with less than three affected individuals. Power calculations under realistic model assumptions suggest that if genetic heterogeneity is absent or limited, then DNA collection from members of these pedigrees could enable the identification of a novel candidate susceptibility gene for BO/OAC in a genome scan.

CONCLUSIONS

This is the largest series of families with BO/OAC yet reported, features of which are consistent with inherited germline predisposition. Further, the SIR of cancers other than OAC/OGJAC was 0.71 among 70 probands, indicating these individuals were not more likely to develop non-OAC cancers.

Familial aggregation of Barrett's oesophagus, oesophageal adenocarcinoma, and oesophagogastric junctional adenocarcinoma in Caucasian adults

BACKGROUND

Although familial clusters of Barrett's oesophagus and oesophageal adenocarcinoma have been reported, a familial predisposition to these diseases has not been systematically investigated.

AIMS

To determine whether Barrett's oesophagus and oesophageal (or oesophagogastric junctional) adenocarcinoma aggregate in families.

PATIENTS AND METHODS

A structured questionnaire eliciting details on reflux symptoms, exposure history, and family history was given to Caucasian case (n=58) subjects with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma, and to Caucasian control (n=106) subjects with symptomatic gastro-oesophageal reflux disease without Barrett's oesophagus. Reported diagnoses of family members were confirmed by review of medical records.

RESULTS

The presence of a positive family history (that is, first or second degree relative with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma) was significantly higher among case subjects compared with controls (24% v 5%; p<0.005). Case subjects were more likely to be older (p<0.001) and male (74% v 43% male; p<0.0005) compared with control subjects. In a multivariate logistic regression analysis, family history was independently associated with the presence of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma (odds ratio 12.23, 95% confidence interval 3.34-44.76) after adjusting for age, sex, and the presence of obesity 10 or more years prior to study enrollment.

CONCLUSIONS

Individuals with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma are more likely to have a positive family history of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma than individuals without Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma. A positive family history should be considered when making decisions about screening endoscopy in patients with symptoms of gastro-oesophageal reflux.

Endoscopic ultrasonography

Over the past two decades, endoscopic ultrasonography (EUS) has undergone a transition from being a novel imaging technique to a clinical diagnostic test that is necessary for the optimal management of gastrointestinal diseases. EUS has established itself as an important diagnostic modality, mainly for the detection and staging of gastrointestinal cancers. As EUS has become more widespread, research has gradually shifted towards studies that explore the effect of EUS on patient management and outcome. These outcome studies have examined the primary clinical applications of EUS, such as esophageal, gastric, pancreatic, and colorectal cancer staging, as well as the role of EUS in the diagnosis of inflammatory pancreatic diseases. Widespread use of EUS has recently led to studies that examine complications associated with the performance of the procedure. Endosonographers have continued efforts to define a clinical role for EUS in other gastrointestinal diseases, such as portal hypertension. EUS-guided fine-needle aspiration (FNA) is continuing to develop into a powerful diagnostic tool for the management of lung cancer and other mediastinal diseases. New applications for EUS-FNA are also emerging. Finally, investigators are continuing to explore the remaining frontier of EUS-guided therapy.

Evaluation of a rapid urine amylase test using post-ERCP hyperamylasemia as a model

OBJECTIVE

The initial diagnosis of acute pancreatitis is often based on clinical criteria together with elevations of serum amylase and lipase. A reliable bedside urine test could facilitate the early diagnosis of pancreatitis. We evaluated a rapid urine amylase test (Rapignost) by using post-ERCP hyperamylasemia as a human model of acute development of hyperamylasemia suggestive of pancreatitis.

METHODS

Seventy-five patients undergoing ERCP were prospectively evaluated. Patients with renal insufficiency, hyperlipidemia, or hyperglycemia were excluded. Before ERCP, patients had serum amylase and lipase measured, and urine amylase tested with the Rapignost test strip. At 4 and 16-24 h post-ERCP, a serum and urine (test strip) amylase were measured again; the adequacy of urine collection was verified by measuring a 2-h creatinine clearance. Patients were clinically assessed for the development of clinical pancreatitis. The concordance of the strip result with post-ERCP hyperamylasemia was assessed.

RESULTS

The sensitivity of the test strip for the detection of hyperamylasemia was greatest at 16-24 h post-ERCP (78%). Specificity was uniformally high (100% specificity at 16-24 h post-procedure). The test strip was positive in all cases of clinical pancreatitis. Of three cases of clinically evident ERCP-induced pancreatitis, only one was urine test strip positive by 4 h post-procedure.

CONCLUSIONS

Using post-ERCP hyperamylasemia as a model, the Rapignost rapid urine amylase test strip was only marginally sensitive but highly specific for hyperamylasemia. The urine test strip was positive in all cases of clinical pancreatitis and may be a useful bedside test for the diagnosis of acute pancreatitis.

High-resolution endoscopic imaging of the GI tract: a comparative study of optical coherence tomography versus high-frequency catheter probe EUS

BACKGROUND

Both optical coherence tomography (OCT) and catheter probe EUS (CPEUS) are candidates for high-resolution imaging of the GI wall, but their potential roles in this clinical context have not been investigated.

METHODS

OCT and CPEUS were used to image normal-appearing portions of the GI tract at the same sites. CPEUS was performed with a 20-MHz or a new 30-MHz catheter probe.

RESULTS

Forty-four histologically confirmed normal sites in 27 patients were evaluated. With OCT, mucosa and muscularis mucosa were clearly seen at all sites. Except for stomach, OCT demonstrated the submucosa in all sites. OCT penetration ranged from 0.7 to 0.9 mm. Microscopic structures such as esophageal glands, intestinal villi, colonic crypts, and blood vessels were easily identified. CPEUS penetration ranged from 10 mm to 20 mm, and 5 to 7 distinct layers were discernible. However, both mucosa and submucosa were seen as thin layers without microscopic detail.

CONCLUSION

OCT resolution is superior to high-frequency CPEUS, but depth of penetration is limited to mucosa and submucosa. OCT images the major structural components of the mucosa and submucosa whereas CPEUS does not. Potentially, OCT and high-frequency CPEUS may be complementary for clinical imaging.

Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones

BACKGROUND

Endoscopic retrograde cholangiography (ERC) may misdiagnose bile duct stones if air bubbles are introduced during contrast injection, and it may also fail to diagnose stones in the presence of bile duct dilation.

METHODS

Our aim was to determine whether intraductal US (IDUS) improves the accuracy of cholangiography and whether it is a useful adjunct in the management of bile duct stones. IDUS with a wire-guided US probe was performed after initial ERC in patients in whom bile duct stones were suspected. The diagnostic accuracy of ERC alone was compared with that of ERC plus IDUS.

RESULTS

ERC with IDUS was performed in 62 patients who were suspected to have bile duct stones. Both IDUS and ERC were performed by the same endoscopist, and ERC was performed with a C-arm fluoroscope. The presence of bile duct stones and/or sludge were confirmed after sphincterotomy and extraction in 34 patients. Overall, the accuracy of ERC combined with IDUS in the diagnosis of bile duct stone and/or sludge was higher than that of ERC alone (97% vs. 87%, p < 0.05). With dilated bile ducts, the diagnostic accuracy of ERC combined with IDUS was also higher than that of ERC alone (95.5% vs. 72.7%, p < 0.05). Additional diagnostic information provided by IDUS included identification of cystic duct stones in 5 patients, characterization of bile duct strictures in 2 patients, and choledochal varices in 1 patient. Performance of wire-guided IDUS required 5% of the total procedure time.

CONCLUSIONS

IDUS improves diagnostic accuracy of ERC and is a useful adjunct to ERC when bile duct stones are suspected.

Prospective evaluation of balloon-sheathed catheter US system

BACKGROUND

Catheter US probes must rely on luminal water to create images because they do not incorporate a water-filled balloon such as that used with a designated echoendoscope. The purpose of this study is to determine the effectiveness and safety of a balloon sheath for the US catheter system.

METHODS

Catheter EUS was performed on 50 patients by using a 2.3 mm 12 MHz or 20 MHz catheter probe. Catheter EUS was used in 47 cases, and a newly developed water-filled balloon sheath was used in 41 cases. Both devices were used in 39 cases. Procedure time, depth of ultrasound penetration, and a subjective assessment of image quality and ease of use were recorded, along with TMN stage as applicable. Catheter EUS findings were confirmed with a standard radial scanning echoendoscopy (S-EUS) in 18 cases.

RESULTS

Catheter probe EUS (C-EUS) and catheter probe plus balloon (CB-EUS) imaging was obtained of 25 esophageal, 8 gastric, 4 rectal, 1 biliary, and 1 duodenal lesion. Time required for the ultrasound portion of the examination was identical with C-EUS and CB-EUS. Depth of penetration increased with CB-EUS with both the 12 MHz and 20 MHz probes (p < 0.05). Subjective assessment of image clarity improved when CB-EUS was used in the esophagus. C-EUS failed to identify 2 esophageal cancers and 2 sets of paraesophageal lymph nodes, and understaged 1 esophageal cancer. The remaining 14 cancers were staged identically by both modalities. The catheter probes with and without the balloon sheath were easy to use, even in markedly narrow esophageal strictures. CB-EUS did not significantly improve resolution in the stomach or rectum. S-EUS confirmed findings of CB-EUS in all 18 cases in which both instruments were used. There were no procedure-related complications.

CONCLUSIONS

For esophageal lesions, CB-EUS improves images compared with C-EUS, and enhances depth of penetration without prolonging or encumbering the examination. CB-EUS offers no advantage over C-EUS in organs other than the esophagus. S-EUS, when possible, remains the preferred imaging modality for esophageal cancers because of the ability to image the celiac axis and other deep structures.

Cervical esophageal perforation during EUS: a national survey

BACKGROUND

EUS is considered to be as safe a procedure as EGD. However, the longer, rigid tip of the echoendoscopes raises concern about cervical esophageal perforation during intubation. Our aim was to determine the rate of this complication.

METHODS

Members of the American Endosonography Club were surveyed by questionnaire to determine the number of EUS examinations performed and the number of cervical esophageal perforations encountered up to June 1999. Each questionnaire was coded to avoid duplicate reporting.

RESULTS

Questionnaires were mailed to 203 members; 86 (42.4%) responded. Cervical esophageal perforation occurred in 16 of 43,852 reported upper EUS procedures at a frequency of 0.03%. Fifteen (94%) patients were elderly. A history of difficult intubation with prior endoscopic procedures was present in 7 (44%) patients. Three patients had large cervical osteophytes. In 9 (56%) patients, the procedure was done by an endosonographer with less than 1 year of experience. Two patients required surgery. One patient died as a result of the perforation and the other 13 (81%) patients were managed successfully with conservative treatment.

CONCLUSIONS

The incidence of cervical perforation during upper EUS may be higher than during EGD. Advanced patient age, difficult intubation during prior upper endoscopy, operator inexperience, and the presence of large cervical osteophytes may contribute to cervical perforation during upper EUS examination.

Methylene blue staining of dysplastic and nondysplastic Barrett's esophagus: an in vivo and ex vivo study

BACKGROUND AND STUDY AIMS

Methylene blue selectively stains specialized columnar epithelium in Barrett's esophagus with high accuracy. We prospectively evaluated the methylene blue staining properties of dysplastic and nondysplastic Barrett's esophagus and the association of these properties with the risk for dysplasia and cancer.

PATIENTS AND METHODS

In a ex vivo study, we mapped, photographed, and sampled esophagectomy specimens with high grade dysplasia and/or early adenocarcinoma before and after methylene blue staining. In a concurrent in vivo study, we performed methylene blue staining and characterized methylene blue stain characteristics. Pathologists estimated the proportion of specialized columnar epithelium in each specimen and graded dysplasia.

RESULTS

We examined 551 biopsies from 47 patients with biopsy-proven Barrett's esophagus and 48 sections from five surgical specimens with Barrett's esophagus and dysplasia and early adenocarcinoma. The accuracy of ex vivo and in vivo methylene blue staining for specialized columnar epithelium was 87% and 90%, respectively. It was influenced by the length of Barrett's esophagus, biopsy location, and the presence of esophagitis and/or dysplasia. Light to absent staining (p = 0.01) and moderate to marked heterogeneity (p = 0.01) were significantly associated with high grade dysplasia or cancer in the univariate analysis and in a multivariate model that adjusted for the length of Barrett's esophagus and the presence of a lesion. These staining characteristics were present in all patients with severe dysplasia and/or adenocarcinoma.

CONCLUSIONS

Highly dysplastic or malignant Barrett's esophagus stains differently with methylene blue. Increased heterogeneity and decreased methylene blue stain intensity are significant independent predictors of high grade dysplasia and/or cancer. These features may help to direct biopsies in patients without a lesion.

The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers

BACKGROUND

Endoscopic ultrasound (EUS) is a minimally invasive, low risk method of diagnosis for chronic pancreatitis (CP). The degree to which endosonographers agree on the features and diagnosis of CP is unknown. For EUS to be considered an accurate test for CP, there must be good interobserver agreement.

METHODS

Forty-five pancreatic EUS examinations were videotaped by 3 experienced endosonographers. Examinations from 33 patients with suspected CP based on typical symptoms, as well as 12 control patients without suspected CP, were included. Eleven experienced endosonographers ("experts") who were blinded to clinical information independently evaluated all videotaped examinations for the presence of CP and the following 9 validated features of CP: echogenic foci, strands, lobularity, cysts, stones, duct dilatation, duct irregularity, hyperechoic duct margins, and visible side branches. The experts also ranked (most to least) which features they believed to be the most indicative of CP. Interobserver agreement was expressed as the kappa (kappa) statistic.

RESULTS

There was moderately good overall agreement for the final diagnosis of CP (kappa = 0.45). Agreement was good for individual features of duct dilatation (kappa = 0.6) and lobularity (kappa = 0.51) but poor for the other 7 features (kappa < 0.4). The expert panel had consensus or near consensus agreement (greater than 90%) on 206 of 450 (46%) individual EUS features including 22 of 45 diagnoses of CP. Agreement on the final diagnosis of CP was moderately good for those trained in third tier fellowships (kappa = 0.42 +/- 0.03) and those with more than 1100 lifetime pancreatic EUS examinations (kappa = 0.46 +/- 0.05). The presence of stones was regarded as the most predictive feature of CP by all endosonographers, followed by visible side branches, cysts, lobularity, irregular main pancreatic duct, hyperechoic foci, hyperechoic strands, main pancreatic duct dilatation, and main duct hyperechoic margins. The most common diagnostic criterion for the diagnosis of CP was the total number of features (median 4 or greater, range 3 or greater to 5 or greater).

CONCLUSIONS

EUS is a reliable method for the diagnosis of chronic pancreatitis with good interobserver agreement among experienced endosonographers. Agreement on the EUS diagnosis of chronic pancreatitis is comparable to other commonly used endoscopic procedures such as bleeding ulcer stigmata and computed tomography of the brain for stroke localization and better than the physical diagnosis of heart sounds.

Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage

BACKGROUND

Esophagogastroduodenoscopy (EGD) is generally indicated for the management of patients admitted to intensive care units (ICUs) with upper gastrointestinal (GI) hemorrhage but its impact in community practice has not been measured. Thus, the effectiveness of 3 EGD factors, viz., accurate initial diagnosis, performance within 24 hours of admission (early EGD), and appropriate intervention, was examined.

METHODS

Records of 214 patients admitted to the ICU of 10 metropolitan hospitals with upper GI hemorrhage were reviewed. Unadjusted and severity-adjusted associations of the 3 EGD factors with length of hospital stay, length of ICU stay, readmission to ICU, recurrent bleeding, surgery, and death were evaluated.

RESULTS

Inaccurate diagnosis occurred in 10% of patients at initial EGD and was associated with significant increases in risk of recurrent bleeding (70% vs. 11%, p < 0.001), rate of surgery (20% vs. 4%, p < 0.05), length of hospital stay (median 7.5 vs. 5 days, p < 0.005), length of ICU stay (median 4 vs. 2 days, p < 0.005), and rate of readmission to ICU (20% vs. 0.6%, p < 0.001). These associations persisted after adjusting for severity of illness. Early EGD performed in 82% of patients was associated with significant severity-adjusted reductions in hospital (-33%: 95% CI [-45%, -18%]) and ICU (-20%: 95% CI [-24%, -3%]) stay. Appropriate intervention at initial EGD, performed in 84% of patients, was associated with reductions in severity-adjusted length of ICU stay (-18%: 95% CI [-32%, 0%]) and rate of recurrent bleeding (odds ratio = 0.37, 95% CI [0.13, 1.06]).

CONCLUSIONS

Early, accurate EGD with appropriate therapeutic intervention is effective as practiced in the community and is associated with improved outcomes for patients with upper GI hemorrhage admitted to the ICU. Inaccurate diagnosis at initial EGD is uncommon but has a significant adverse association with all outcome measures.

Effectiveness of ERCP in cholangitis: a community-based study

BACKGROUND

Although experts have demonstrated the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in cholangitis, the effectiveness of ERCP in unselected patients has not been measured. The aim was to investigate the clinical impact of ERCP performed at any time and of early ERCP (within 24 hours of admission) in patients with a primary discharge diagnosis of cholangitis.

METHODS

A retrospective record review of patients admitted to eight area hospitals with an International Classification of Diseases (ICD)-9 diagnosis consistent with cholangitis was performed. Extracted data included clinical characteristics, ERCP findings, and patient outcome. The associations of ERCP overall and early ERCP with length of stay were examined. Confounding factors including severity of illness, etiology of cholangitis, and hospital type were adjusted for in a multivariate analysis.

RESULTS

A total of 116 patients were studied. ERCP was performed in 71 patients with endoscopic therapy administered in 57 (80%). ERCP overall was not associated with any change in length of hospital stay. However, compared with other invasive biliary procedures, ERCP was associated with a shorter hospital stay (median 5 vs. 9.5 days, p = 0.01) and a 36% (95% CI [5%, 57%]) reduction in severity-adjusted length of stay. Patients who had early ERCP had a significantly shorter hospital stay than those who had delayed ERCP (median 4 vs. 7 days, p < 0.005) and early ERCP was associated with a 34% (95% CI [11%, 48%]) reduction in severity-adjusted length of stay.

CONCLUSION

Early ERCP may be an effective strategy for shortening the length of stay in patients hospitalized with cholangitis.

Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?

BACKGROUND

Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem. This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage.

METHODS

In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal.

RESULTS

Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths.

CONCLUSIONS

A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers.

Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer

BACKGROUND

Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known.

METHODS

Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures.

RESULTS

One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers.

CONCLUSIONS

There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines.

Methylene blue-directed biopsies improve detection of intestinal metaplasia and dysplasia in Barrett's esophagus

BACKGROUND

Endoscopically applied methylene blue selectively stains specialized columnar epithelium in Barrett's esophagus.

METHODS

The diagnostic yield and cost of cancer surveillance in patients with Barrett's esophagus using methylene blue-directed biopsies (MBDB) were compared with surveillance using a "jumbo" random biopsy technique in a prospective, sequential, controlled trial. Esophagogastroduodenoscopy was performed with either MBDB or random biopsy in a randomized sequence. The proportions of various types of epithelia in each biopsy were estimated and dysplasia was graded in a blinded fashion.

RESULTS

Forty-three patients with short- (n = 8), limited- (n = 10), and long-segment (n = 25) Barrett's esophagus were studied. Using MBDB technique, the average number of biopsies obtained per patient was significantly lower and the proportion of specialized columnar epithelium in each specimen was significantly higher compared with random biopsy. Dysplasia or cancer was diagnosed in significantly more MBDB specimens (12% vs. 6%, p = 0.004). Despite fewer biopsies per patient using MBDB, dysplasia or cancer was diagnosed in significantly more patients (44% vs. 28%, p = 0.03) than by random biopsy technique. MBDB cost less and detected more cancers than random biopsy.

CONCLUSIONS

MBDB is a more accurate and cost-effective technique than random biopsy for diagnosing specialized columnar epithelium and dysplasia/cancer, particularly in long-segment Barrett's esophagus.

Endosonographic assessment of multimodality therapy predicts survival of esophageal carcinoma patients

BACKGROUND

Standard endosonographic (EUS) staging criteria are unreliable for staging esophageal carcinoma after neoadjuvant therapy; however, measurement of tumor size reduction can identify patients who have achieved a pathologic response. In the current study the authors prospectively compared survival between patients classified as responders and those classified as nonresponders by EUS.

METHODS

The maximal transverse cross-sectional area of the tumor was measured before and after neoadjuvant therapy in patients who were candidates for multimodality treatment. Response was defined as a > or = 50% reduction in tumor area.

RESULTS

A total of 59 patients at 2 centers were followed for a median of 19 months. EUS assessed response in 34 patients (58%). Overall, responders had a median survival of 17.6 months compared with 14.5 months for nonresponders (P < 0.005). Survival was significantly longer in responders compared with nonresponders in the patient subgroup who underwent surgical resection (19.7 months vs. 14.6 months; P < 0. 005), the patient subgroup with adenocarcinoma (21.4 months vs. 10.8 months; P < 0.005), and the patient subgroup initially classified as having T3N1 disease (17.6 months vs. 14.1 months; P < 0.05). Survival was not found to differ significantly between responders and nonresponders in the subgroup of patients with squamous cell carcinoma. EUS response was the only clinical variable that was associated with survival time in a multivariate analysis (relative hazard = 0.27; P < 0.005).

CONCLUSIONS

Patients with esophageal carcinoma who respond to neoadjuvant treatment as identified by EUS measurement of reduction in tumor size have a significantly better prognosis than nonresponders.

The accuracy of diagnosis and procedural codes for patients with upper GI hemorrhage

BACKGROUND

Little is known about the accuracy of diagnostic and procedural codes for common gastrointestinal (GI) conditions and endoscopic procedures.

METHODS

Eight hundred eighty-two patients with upper GI hemorrhage admitted in 1994 to 1 of 13 regional hospitals were studied. Based on endoscopy reports, the source of hemorrhage, performance of upper endoscopy and use of endoscopic therapy were determined, and we assessed the sensitivity and positive predictive value of discharge codes for measuring the source of hemorrhage and use of upper endoscopy.

RESULTS

The sensitivity and positive predictive value of principal diagnosis coding for source of hemorrhage were typically 85% to 95%. The sensitivity and predictive value of coding for upper endoscopy were 97.7% and 99.9%, respectively, and were 72.3% and 99.4%, respectively, for endoscopic therapy. Accuracy did not differ between the 4 major teaching and 9 other hospitals.

CONCLUSIONS

Hospital-based diagnostic and procedural codes are a reasonably accurate source of data for clinical and outcomes analyses of upper GI hemorrhage. In particular, it is possible to discern from these data the source of hemorrhage and the overall use of upper endoscopy.

High-resolution endoscopic imaging of the GI tract using optical coherence tomography

BACKGROUND

Optical coherence tomography (OCT) has demonstrated the microscopic structure of the gastrointestinal (GI) tract mucosa and submucosa in vitro. We evaluated a prototype OCT system and assessed the feasibility of OCT in the human GI tract.

METHODS

The 2.4 mm diameter prototype OCT probe, inserted through an endoscope, provides a 360-degree radial scan. Images (6.7 frames/sec) are displayed on a television monitor. Tissue contact is not required. In patients undergoing elective endoscopy, OCT images were obtained of normal mucosa (confirmed by biopsy).

RESULTS

Seventy-two sites were imaged (38 patients): esophagus (21), stomach (12), duodenum (11), terminal ileum (4), colon (15), and rectum (9). Varying the distance between the probe and the mucosal surface produced images of the GI wall of varying depth. When held about 1 mm above the mucosal surface, the images consisted of mucosal structures such as colonic crypts, gastric pits, and duodenal villi. With the probe held against the wall, the OCT image comprised several layers interpreted as mucosa, muscularis mucosae, and submucosa. Structures including blood vessels were evident within the submucosa. A probe with a 0.5 mm working distance to the focal point provided the best images. Reducing the frame rate to 4.0 per second facilitated image interpretation.

CONCLUSIONS

OCT is feasible in the human GI tract and provides interpretable high-resolution images of mucosa and submucosa.

Endoscopic ultrasonography

Endosonography is primarily a diagnostic imaging modality, but new therapeutic applications are being developed. Miniprobe technology (ultrasound catheter probes) has led to new clinical applications. The staging of gastrointestinal cancers remains the major accepted indication for endosonography. Other conditions, such as chronic pancreatitis, portal hypertension, and inflammatory bowel diseases, are also being evaluated with endosonographic imaging.

Prospective evaluation of an over-the-wire catheter US probe

BACKGROUND

Pancreaticobiliary strictures identified at endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated by intraductal ultrasonography (US). Two major difficulties are that sphincterotomy may be required and the stricture may not be traversable. We prospectively evaluated the ease and success of intraductal US using a new over-the-wire catheter US probe.

METHODS

Biliary or pancreatic strictures discovered at ERCP were imaged with the new probe. Intraductal US performance times, image clarity, imaging depth and technical ease were measured.

RESULTS

Twenty-one patients with a variety of inflammatory and malignant pancreaticobiliary lesions were studied. Thirteen of the 16 (81%) masses imaged by intraductal US were 10 mm or less in diameter. Sphincterotomy was not required. All strictures traversed by a guidewire were imaged. The sphincter of Oddi was successfully imaged in all patients with intact normal sphincters. Performance of intraductal US was rated as technically easy in all cases and image clarity was rated as good or very good in 15 of 21 (71%) cases.

CONCLUSIONS

The new over-the-wire catheter US probe facilitates intraductal US. Sphincterotomy is avoided and strictures are successfully traversed. This probe makes it possible to image the sphincter of Oddi.

A multicenter U.S. experience with EUS-guided fine-needle aspiration using the Olympus GF-UM30P echoendoscope: safety and effectiveness

BACKGROUND

The aim of this study was to determine the safety, efficacy, and accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration using the GF-UM30P echoendoscope.

METHODS

GF-UM30P-guided EUS-guided fine-needle aspiration results from 3 EUS referral centers were prospectively recorded. Successful sampling required that the needle tip be seen within the lesion on at least 1 pass. Aspirates were considered adequate if they were diagnostic for cancer, contained suspicious or atypical cells, or were adequately cellular for interpretation but nondiagnostic.

RESULTS

EUS-guided fine-needle aspiration was attempted on 162 lesions in 152 patients with no complications. Sampling was successful in 150 of 162 (93%) attempts (mean lesion size 2.5 +/- 1.2 cm (range 0.7 to 6.0 cm). Aspirates were adequately cellular in 138 of 162 (85%) attempts (43% diagnostic, 15% suspicious and/or atypical cells, 27% adequate cellularity but nondiagnostic). Sampling failed in 12 of 162 (7%) attempts. Ten of 12 (83%) failures and 11 of 12 (92%) inadequate aspirates occurred when lesions measured less than 2 cm. The sensitivity for malignancy was 93% if only successfully sampled lesions with surgically confirmed negative results were included. However, it was 68% if all attempts were included and when unconfirmed high/moderate suspicion negative results were counted as false negatives and low suspicion negative results as true negatives.

CONCLUSIONS

The GF-UM30P may be clinically useful for EUS-guided fine-needle aspiration if a curved linear array instrument is unavailable.

Real-time in vivo imaging of human gastrointestinal ultrastructure by use of endoscopic optical coherence tomography with a novel efficient interferometer design

We report on the design and initial clinical experience with a real-time endoscopic optical coherence tomography (EOCT) imaging system. The EOCT unit includes a high-speed optical coherence tomography interferometer, endoscope-compatible catheter probes, and real-time data capture and display hardware and software. Several technological innovations are introduced that improve EOCT efficiency and performance. In initial clinical studies using the EOCT system, the esophagus, stomach, duodenum, ileum, colon, and rectum of patients with normal endoscopic findings were examined. In these initial investigations, EOCT imaging clearly delineated the substructure of the mucosa and submucosa in several gastrointestinal organs; microscopic structures such as glands, blood vessels, pits, villi, and crypts were also observed.

Use of open access in GI endoscopy at an academic medical center

BACKGROUND

Open access endoscopy systems (those in which endoscopy is performed without prior gastroenterology consultation) are becoming more common in the current cost-conscious environment. The aim of this study was to compare appropriateness and yield of endoscopy for patients referred for open access endoscopy with those for patients who had prior contact with a gastroenterologist. We also evaluated patients' preference for undergoing open access endoscopy as opposed to having prior consultation with a gastroenterologist and compared preparedness for endoscopic procedures between the two groups.

METHODS

The cases of all outpatients referred for upper endoscopy and colonoscopy were assessed prospectively over a 5-month period. American Society for Gastrointestinal Endoscopy (ASGE) guidelines for indications for gastrointestinal endoscopy were used to determine appropriateness of referrals. Significant pathologic findings were rated independently by two investigators using defined criteria. Patients' opinions regarding preparedness for endoscopy and referral preference were measured by means of questionnaires administered before endoscopy.

RESULTS

Eighty-six percent of endoscopies after consultation with gastroenterologists were performed for accepted indications compared with 65% of open access procedures (p < 0.01). Significant pathologic findings were present in 40% of the former group compared with 28% of those undergoing open access endoscopy (p < 0.01). Significant pathologic findings were found in 37% of endoscopies performed for indications listed in the ASGE guidelines compared with 20% for unlisted indications (p < 0.01). Forty percent of patients referred for open access endoscopy would have preferred prior consultation with a gastroenterologist.

CONCLUSION

Patients initially seen by a gastroenterologist are more likely to undergo endoscopy for accepted indications, and the yield of endoscopy is higher than among patients referred through an open access system. The system of open access endoscopy as currently practiced may have to be reassessed.

Procedure-specific outcomes assessment for endoscopic ultrasonography

Endosonography (EUS) is a relative newcomer to the field of gastrointestinal endoscopy. Nevertheless, two prospective studies with similar results have shown that EUS leads to a change in management in roughly two-thirds of patients in whom it is performed, with many of these changes being to less invasive or less expensive management. Preliminary investigations on the use of catheter probes for performing EUS have shown similar effects. Specific investigations on the effect of EUS on the outcomes of patients with submucosal tumors, esophageal cancers, pancreatic cancers, and rectal cancers need to be performed. Selective studies have demonstrated EUS to be cost-effective for the management of submucosal tumors and ampullary tumors. The complication rate of EUS appears to be comparable to that of upper endoscopy. There is little or no information regarding training in EUS, practice variation, or affect of EUS on quality of life.

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS

BACKGROUND

Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our objective in this study was to determine the accuracy of Eus in detecting celiac axis lymph node metastasis in patients with esophageal carcinoma.

METHODS

Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination.

RESULTS

Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease.

CONCLUSION

EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher.

Catheter probe assisted endoluminal US in inflammatory bowel disease

BACKGROUND

Use of an echocolonoscope to examine patients with inflammatory bowel disease is technically difficult. Catheter probe assisted endoluminal ultrasonography (US) may be a feasible alternative.

METHODS

Determination of demographic information and clinical disease activity was followed by colonoscopy with biopsy. Catheter probe assisted endoluminal US was performed with measurements of thickness of the intestinal wall and evaluation of the structure of the sonographic layers.

RESULTS

Twenty-eight patients, 7 with ulcerative colitis, 11 with Crohn's disease, and 10 healthy control subjects participated in a prospective study. Mean colonic wall thickness was 2.2 +/- 0.1 mm (controls) compared with 4. 1 +/- 0.4 mm (ulcerative colitis) (p < 0.001) and 4.4 +/- 0.4 mm (Crohn's disease) (p < 0.001). Among patients with ulcerative colitis, colonic wall thickness correlated with severity of colonoscopic changes (r = 0.84, p = 0.02). Among patients with Crohn's disease, loss of endosonographic layer structure correlated with disease activity score (r = 0.8, p = 0.003), and colonic wall thickness correlated with the severity of histologic changes (r = 0. 62, p = 0.04).

CONCLUSIONS

Catheter probe assisted endoluminal US is technically feasible in the care of patients with inflammatory bowel disease. Endosonographic measurements of colonic wall thickness and layer structure provide clinically significant information.

Prospective determination of distal colon findings in average-risk patients with proximal colon cancer

BACKGROUND

Recent guidelines indicate that colonoscopy and sigmoidoscopy are both acceptable options for screening average-risk patients for colorectal cancer. Retrospective studies have found that a majority of patients with cancer proximal to the splenic flexure have a normal screening flexible sigmoidoscopy.

METHODS

This was a multicenter, prospective description of colonoscopic findings and family history in consecutive patients with proximal colon cancer.

RESULTS

Among 116 prospectively identified average-risk patients with cancer proximal to the splenic flexure, 40 (34.5%) had neoplasia distal to the splenic flexure. The prevalence of patients with adenomas greater than or equal to 1 cm, with only one tubular adenoma less than 1 cm, and with only hyperplastic polyps were 16.4%, 8.6%, and 6.9%, respectively.

CONCLUSIONS

Most average-risk patients with cancer proximal to the splenic flexure will have a normal screening flexible sigmoidoscopy. These patients have an unexpectedly high prevalence of large distal adenomas, but the prevalence of both single small tubular adenomas and hyperplastic polyps alone is similar to that expected during screening of the general population. Clinicians and payers should continue to seek methods to improve the cost-effectiveness and availability of screening colonoscopy in average-risk persons.

Prospective comparative evaluation of video US endoscope

BACKGROUND

Limitations in the technical capabilities of the fiberoptic echoendoscope often necessitate concurrent diagnostic endoscopy at the time of an endosonographic (EUS) examination. Our aim was to determine whether a new video echoendoscope would allow the performance of EUS without diagnostic endoscopy.

METHODS

EUS examinations on all patients at two centers were initiated with a fiberoptic echoendoscope (period of 5 weeks) or a video echoendoscope (period of 6 weeks). Note was made of need for concurrent diagnostic endoscopy. The endosonographer also rated the mechanical, optical, and sonographic performance of the video instrument using a 9-point comparative scale (1 = much worse, 5 = equal to, and 9 = much better than fiberoptic echoendoscope).

RESULTS

A total of 103 patients including 40 and 28 with mural lesions and 22 and 15 with retroperitoneal lesions were examined with the fiberoptic and video echoendoscopes, respectively. Mean values for parameters rating the video echoendoscope's mechanical performance ranged between 5.0 and 5.9, optical performance ranged between 6.6 and 7.5, and sonographic performance ranged between 4.6 and 4.9. Concurrent diagnostic endoscopy was required less frequently when patients with mural lesions (18% vs. 70%, p < 0.005) or patients with retroperitoneal lesions (0% vs. 14%, p = no significance) were examined with the video echoendoscope compared with the fiberoptic echoendoscope.

CONCLUSIONS

Moderately improved optics and slightly better mechanical characteristics of the new video echoendoscope allow the performance of EUS without concurrent diagnostic endoscopy in the majority of patients.