[Comparison of the accuracy of rectal endoscopic sonography and magnetic resonance imaging in the diagnosis of colorectal endometriosis]

OBJECTIVE

To compare the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of colorectal endometriosis.

METHODS

In retrospective study, 407 patients operated on service of gynecology of Tenon hospital for deep endometriosis with suspected colorectal involvement. All patients underwent MRI and then RES.

RESULTS

In the study, 239 patients (59%) had colorectal endometriosis which were diagnosed with the histology. The sensitivity, specificity, positive and negative predictive value (PPV and NPV) of RES and MRI for the diagnosis of colorectal endometriosis were respectively 92%, 87%, 91%, 88% and 85%, 88%, 91%, 80%. The accuracy of RES was not significantly different than MRI (90% versus 86%, P=0.09).

CONCLUSION

RES is a good exam to diagnose colorectal endometriosis. It is able to improve diagnosis performances.

Pulmonary delivery of dry powders to rats: tolerability limits of an intra-tracheal administration model

The inhaled route is increasingly developed to deliver locally acting or systemic therapies, and rodent models are used to assess tolerance before clinical studies. Endotracheal intubation of rats with a probe which generates powder aerosols enables controlled administration of drug directly into the respiratory tract. However, preliminary observations of intratracheal powder administration procedures have raised concerns with regard to pulmonary safety. The aim of the present work was to evaluate the safety of intra-tracheal administration of dry powder in a rat model. Sixty animals were administered various volumes of air alone, lactose or magnesium stearate through a Microsprayer(®) (Pencentury, USA). The mass of powder actually delivered to each animal was calculated. Rats were sacrificed immediately after administration, and the lungs, trachea and larynx were removed and examined for gross pathology. The mass of powder delivered varied, the full dose being rarely delivered. About one third of the administration procedures resulted in respiratory failure, and macroscopic pulmonary lesions were observed in about 55% of animals. Lung damages were observed with air alone, lactose and magnesium stearate. In conclusion, artifacts observed with this technique may limit the relevance of the model. These observations are particularly important in the context of regulatory toxicity studies.

Accuracy of transvaginal sonography and rectal endoscopic sonography in the diagnosis of deep infiltrating endometriosis

OBJECTIVES

To compare the accuracy of transvaginal sonography (TVS) and rectal endoscopic sonography (RES) for the diagnosis of deep infiltrating endometriosis (DIE), with respect to surgical and histological findings.

METHODS

This was a longitudinal study of 81 consecutive patients referred for surgical management of DIE, who underwent both TVS and RES preoperatively. The diagnostic criteria were identical for TVS and RES, and were based on visualization of hypoechoic areas in specific locations (uterosacral ligaments, vagina, rectovaginal septum and intestine). We calculated the sensitivity, specificity, predictive values and accuracy of TVS and RES for the diagnosis of DIE.

RESULTS

Endometriosis was confirmed histologically in 80/81 (98.7%) patients. Endometriomas and DIE were present in 43.2% and 97.5% of the women, respectively. For the diagnosis of DIE overall, TVS and RES, respectively, had a sensitivity of 87.3% and 74.7%, a positive predictive value of 98.6% and 98.3%, and an accuracy of 86.4% and 74%. For the diagnosis of uterosacral endometriosis, they had a sensitivity of 80.8% and 46.6%, a specificity of 75% and 50.0%, a positive predictive value of 96.7% and 89.5% and a negative predictive value of 30% and 9.3%. For the diagnosis of intestinal endometriosis, they had a sensitivity of 92.6% and 88.9%, a specificity of 100% and 92.6%, a positive predictive value of 100% and 96% and a negative predictive value of 87% and 80.6%.

CONCLUSION

TVS is apparently more accurate than is RES for predicting DIE in specific locations, and should thus be the first-line imaging technique in this setting.

Accuracy of rectal endoscopic ultrasonography and magnetic resonance imaging in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis

OBJECTIVE

To compare the accuracy of rectal endoscopic ultrasonography (REU) and magnetic resonance imaging (MRI) for predicting rectal wall involvement in patients presenting histologically proven deeply infiltrating endometriosis (DIE).

METHODS

This was a retrospective study of a continuous series of 81 patients presenting histologically proven DIE who underwent preoperative investigations using both REU and MRI. The sonographer and the radiologist, who were unaware of the clinical findings and patient history, but knew that DIE was suspected, were asked whether there was involvement of the digestive wall.

RESULTS

Rectal DIE was confirmed histologically in 34 of the 81 (42%) patients. For the diagnosis of rectal involvement, sensitivity, specificity and positive and negative predictive value for REU were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2%.

CONCLUSION

The sensitivity and negative predictive value of REU were higher than those of MRI suggesting that REU performs better than MRI in the diagnosis of rectal involvement for patients presenting with DIE. Prospective studies with a large number of patients are needed in order to validate these preliminary results.

[Functional intestinal disorders: assessment and perception by physicians of their patients perception. Results of two national studies]

OBJECTIVE

In 1999, a first national survey on functional intestinal disorders (FID) revealed the patients' good perception of the medical corps and treatments proposed. The aim of the present study was to assess the physicians' perception of their patients, their symptoms and their degree of satisfaction.

METHODS

The survey was conducted among the physicians who had recruited the patients of the initial study. Eight hundred and eighty five replies were analysed (general practitioners--GPs: 88%; gastro-enterologists--GE: 11%).

RESULTS

The mean number of patients with FID seen in one week was of 11.40 (GP: 10.80; GE: 16.29). Thirty percent of patients were seen for the first time by a GP and 65 percent by a GE. The mean yearly number of consultations for these patients was of 7.16 for the GPs and 3.81 pour les GEs. A coloscopy was prescribed by 49% of GPs and 66% of GEs. The pain and transit disorders mentioned in 98 and 78.7% of cases had evolved over a mean of 56.57 months.

COMMENTS

Although aware of the repercussion of FID in daily life, the practitioners evaluated a psychological component of 69% in the expression of the disorder. They considered the pain intense in 6% of cases versus the 41% expressed by the patient. The scores out of 10 for 8 items showed a mean result of 6.86 in their evaluation of the degree of the patients' understanding of their disease and its treatment, and of 6.13 for the quality of the medical act. These same criteria, assessed one year earlier by the patients themselves, showed better scores.

[Gastrointestinal functional disorders. National evaluation survey of patient symptoms and management]

OBJECTIVE

An anonymous self-administered questionnaire was completed by patients with gastrointestinal functional disorders to determine symptoms and management strategies employed.

METHODS

The questionnaire was filled out by 1266 patients who complained of abdominal pain in 8 out of 10 cases as well as disturbed bowel movements and abdominal distension.

RESULTS

Half of the patients had started self medication, generally before consulting their general practitioner. The patients were generally satisfied with their medical care. Superior efficacy was observed for antispasmodics in combination or not with anxiolytic agents (75%, 71% and 69% efficacy respectively). The digestive disorders led to an interruption of occupational activities in 21% of the patients.

DISCUSSION

Optimal management of patients with this benign chronic disorder that nevertheless has a major impact on their quality of life requires sufficient knowledge of the opinions of both the patients and their physicians. A second survey on this question has been initiated.

Anal carcinoma: prognostic value of endorectal ultrasound (ERUS). Results of a prospective multicenter study

BACKGROUND AND STUDY AIMS

The classification of anal carcinoma is based on the clinical examination and the estimation of the tumor height (Union Internationale Contre le Cancer (UICC) 1987 Classification). This classification has a direct therapeutic application since tumors which are designated T1 and T2 are generally treated by radiotherapy whereas T3, T4 or N+ lesions are treated by concomitant radiation and chemotherapy. The aim of this prospective multicenter study was to evaluate endorectal ultrasound (ERUS) and to define an ERUS-based classification.

PATIENTS AND METHODS

Between January 1994 and May 1997, 146 patients (42 men and 104 women; mean age, 63) from eight different centers were studied prospectively. The ERUS classification incorporates disease of the anal canal and the perirectal lymph nodes, thus: usT1 describes involvement of the mucosa and submucosa with sparing of the internal sphincter; usT2, involvement of the internal sphincter with sparing of the external sphincter; usT3, involvement of the external sphincter; usT4, involvement of a pelvic organ; N0 describes no suspicious perirectal lymph nodes, and N+, perirectal lymph nodes fulfilling endosonographic criteria for malignancy (e.g. round, hypoechoic). Tumors classified as UICC T1-T2 (<4cm) N0 were treated by radiotherapy alone, whereas lesions with a UICC classification of T2 (> 4 cm), T3-T4, N0-N1-2-3 received combined radiochemotherapy.

RESULTS

Data concerning the treatment and follow-up were available for 115/146 patients (78.7%). We compared the prognostic importance of the two classification schemes for treatment response and the rate of local relapse (chi-squared test). A significantly greater proportion of T1-T2N0 lesions classified by ERUS had a complete response to treatment than those classified by conventional UICC staging (94.5% vs. 80%, respectively; P = 0.008). The ERUS T and N stage were significant predictors of relapse (P=0.001 and P=0.03, respectively) whereas the corresponding clinical (UICC) stages were not (P = 0.4 and P = 0.5, respectively). Using a Cox model, usT stage was the only significant predictive factor for patient survival.

CONCLUSION

This muticenter prospective study demonstrated the superiority of ERUS-based staging over traditional clinical staging in the prediction of important outcomes such as local tumor recurrence and patient survival.

[Comparison of endoscopic ultrasound and magnetic resonance imaging in severe pelvic endometriosis]

Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Digestive infiltration is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown with incomplete resection and sometimes repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectosigmoid infiltration but their usefulness in the preoperative staging is still to be evaluated. The aim of this work was to evaluate and compare both techniques in the preoperative detection of deep pelvic endometriosis, particularly digestive infiltration.

PATIENTS AND METHODS

From 1996 to 1998, 48 women with painful deep pelvic endometriosis had preoperative imaging exploration with endoscopic ultrasonography and MRI, and were operated on in order to attempt complete endometriosis resection. Patients were proposed for laparoscopic resection if endoscopic ultrasonography and/or MRI did not reveal digestive infiltration or for open resection if endoscopic ultrasonography and/or MRI were positive for digestive infiltration.

RESULTS

Endoscopic ultrasonography and/or MRI led to suspicion of digestive endometriosis in 16 patients. Surgical resection was performed in 12 and digestive wall invasion was histologically demonstrated. At final follow-up, all patients had a dramatic decrease of their symptoms. The remaining 4 patients refused digestive resection and had only laparoscopic gynecologic resection. Infiltration although not histologically proven was very likely both on operative findings and clinical evolution. Digestive infiltration was preoperatively excluded in the 32 other patients. All had a laparoscopic treatment without digestive resection and pain diminished in all patients. In the 12 patients group who had digestive resection, digestive infiltration was correctly diagnosed by endoscopic ultrasonography in all cases (no false negative) whereas MRI, even with the use of endocoil antenna, led to correct diagnosis in 8 out of 12 cases. When endoscopic ultrasonography was negative for digestive infiltration, laparoscopic resection of lesions at surgery appeared complete in all cases. For the 16 patients with presumed digestive infiltration, sensitivity of endoscopic ultrasonography and MRI was 100 and 75% respectively, with a 100% specificity in both cases. MRI appeared very accurate for the detection of ovarian endometriotic locations. MRI was more sensitive but less specific than endoscopic ultrasonography for the diagnosis of isolated endometriotic recto-vaginal septum and utero-sacral ligaments lesions.

CONCLUSION

Endoscopic ultrasonography was the best technique for the diagnosis of digestive endometriotic infiltration, which complicates the therapeutic strategy. MRI, however, allows more complete staging of other pelvic endometriotic lesions.

Biliary varices on endoscopic ultrasonography: clinical presentation and outcome

BACKGROUND AND STUDY AIMS

Bile duct varices are not a well-recognized feature of portal venous obstruction. The aim of the present study was to describe the clinical and endosonographic features of biliary involvement in patients with extrahepatic portal venous obstruction (EPVO).

PATIENTS AND METHODS

A retrospective study was conducted of the clinical features, outcome, and endosonographic findings (using Olympus EUM-3 or EUM-20 probes) in 21 patients with EPVO and endosonographic features of biliary varices. Biliary varices were defined as multiple, large, serpiginous, anechoic vascular channels in and/or surrounding the extrahepatic biliary tracts.

RESULTS

Biliary varices have not previously been visible using conventional imaging methods (computed tomography and ultrasonography). They were identified using EUS in the wall of the common bile duct in 16 patients (76%), surrounding the common bile duct (CBD) in 11 patients (52%), and in the gallbladder in nine (43%). The varices were the cause of obstructive jaundice in three of the 21 patients (14%), but only when they were in the wall of the CBD. Two of these patients were treated using portosystemic shunting, and the other received a biliary endoprosthesis. The EUS examination also provided evidence of unrecognized pancreatic or biliary tumors in three other patients with EPVO of undetermined origin.

CONCLUSIONS

EUS can serve to diagnose biliary varices in patients with EPVO and jaundice. Although biliary varices are mainly asymptomatic, they may cause obstructive jaundice when they are located in the wall of the CBD. EUS can also detect unrecognized malignant tumors in patients with EPVO of undetermined origin.

Rectosigmoid endometriosis: endoscopic ultrasound features and clinical implications

BACKGROUND AND STUDY AIMS

The main area of the gastrointestinal tract affected by deep pelvic endometriosis is the rectosigmoid colon in 3-37% of cases. Due to the risk of infiltration and the clinical symptoms of endometriosis, with pain and infertility, the condition may require surgical resection. Preoperative imaging diagnosis of rectosigmoid involvement is therefore important. Rectal endoscopic ultrasonography (EUS), which is already used for the staging of anorectal carcinoma and submucosal lesions, may be a promising technique for this indication. The present study was conducted in order to describe the endosonographic appearance of rectosigmoid endometriosis, and to define the potential relevance of the technique to the choice of resection method.

PATIENTS AND METHODS

Between 1993 and 1997, 46 women (mean age 31) with deep pelvic endometriosis underwent imaging investigations and surgical resection. The clinical and imaging findings, and the surgical and histological features identified--mainly with regard to infiltration of the rectal wall--were compared retrospectively. The impact of the EUS findings on the decision on whether or not to carry out resection, either by laparoscopy or open abdominal surgery, was also examined.

RESULTS

When there was deep pelvic endometriosis with suspected rectal wall infiltration, EUS showed normal anatomy in nine patients, endometriotic lesions without rectal wall infiltration in 12, and typical rectal infiltration in 25. The lesions were confirmed by the surgical findings during therapeutic laparoscopy (n = 22) and laparotomy (n = 25), as well as by clinical follow-up. Rectal wall infiltration, demonstrated in all cases using EUS, had initially been suspected on the basis of clinical examinations, rectoscopy, barium enema, computed tomography, and magnetic resonance imaging in 62%, 50%, 33%, 67% and 66% of cases, respectively.

CONCLUSIONS

EUS is a simple and noninvasive technique capable of correctly diagnosing rectal wall infiltration in deep pelvic endometriosis. It may be helpful in determining the choice between laparoscopy and laparotomy when complete resection is indicated.

Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours

BACKGROUND/AIM

Some endoscopic ultrasonographic (EUS) features have been reported to be suggestive of malignancy in gastrointestinal stromal cell tumours (SCTs). The aim of this study was to assess the predictive value of these features for malignancy.

METHODS

A total of 56 histologically proven cases of SCT studied by EUS between 1989 and 1996 were reviewed. There were 42 gastric tumours, 12 oesophageal tumours, and two rectal tumours. The tumours were divided into two groups: (a) benign SCT, comprising benign leiomyoma (n = 34); (b) malignant or borderline SCT (n = 22), comprising leiomyosarcoma (n = 9), leiomyoblastoma (n = 9), and leiomyoma of uncertain malignant potential (n = 4). The main EUS features recorded were tumour size, ulceration, echo pattern, cystic spaces, extraluminal margins, and lymph nodes with a malignant pattern. The two groups were compared by univariate and multivariate analysis.

RESULTS

Irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern were most predictive of malignant or borderline SCT. Pairwise combinations of the three features had a specificity and positive predictive value of 100% for malignant or borderline SCT, but a sensitivity of only 23%. The presence of at least one of these three criteria had 91% sensitivity, 88% specificity, and 83% predictive positive value. In multivariate analysis, cystic spaces and irregular margins were the only two features independently predictive of malignant potential. The features most predictive of benign SCTs were regular margins, tumour size < or = 30 mm, and a homogeneous echo pattern. When the three features were combined, histology confirmed a benign SCT in all cases.

CONCLUSIONS

The combined presence of two out of three EUS features (irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern) had a positive predictive value of 100% for malignant or borderline gastrointestinal SCT. Tumours less than 30 mm in diameter with regular margins and a homogeneous echo pattern are usually benign.

[Anorectal echo-endoscopy: applications in pediatrics]

PEDIATRIC INDICATIONS: Anorectal echoendoscopy is widely used in adults for the pretreatment work-up of rectal cancer and for the exploration of fecal incontinence. It can also be useful in the pediatric setting as recently described with rotative or linear heads. The exploration can be performed after an evacuating enema or if needed after giving a neuroleptanalgesic. The anorecal walls and neighboring areas-bladder, genital organs, perirectal spaces, vessels-can be explored. The ultrasonographic aspect of the walls is similar to that described in adults although less thick, particularly at the level of the anus sphincters. Signs of defects, abscesses and fistulizations are the same as in adults. BOWEL DISORDERS AND INCONTINENCE: Echoendoscopy can characterize rare subepithelial tumors of the rectum and vascular anomalies, but its main interest is for the exploration of bowel disorders and incontinence, particularly after surgical treatment for anorectal malformations. The quality of the muscular tissue and the quality of the surgical repair can be assessed before deciding on the need for a second operation. In this context, anorectal echoendoscopy can also disclose Hirschsprung's disease and other forms of idiopathic megarectum, including certain types with major thickening of the internal sphincter. It can also detect defects induced by prior disimpaction maneuvers. A NONINVASIVE EXAM: Anorectal echoendoscopy is a promising exploration technique in pediatric gastroenterology. Descriptions of the sphincters and anorectal anatomy are very precise and descriptions of functional disorders, whether primary or secondary to surgery, can be quite helpful for guiding subsequent management.

Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis

The objective of this work was to assess the advantages and the role of rectal endoscopic ultrasonography (EUS) when establishing evidence of infiltration of the rectal wall in patients with proven deep pelvic endometriosis. To this end we performed a retrospective study between July 1993 and December 1996 of a continuous series of 38 patients who presented with deep pelvic endometriosis which was confirmed histologically. The EUS results were considered normal in nine cases (23.7%). In 12 cases (31.6%) EUS revealed an image compatible with infiltration of the uterosacral ligaments and/or the rectovaginal septum without any associated bowel infiltration. In 17 cases (44.7%) EUS revealed an image compatible with deep infiltration of the intestinal wall. Sixteen of these 17 patients underwent laparotomy with bowel resection. The histological results confirmed in each of these 16 patients (100%) that there was deep infiltration of the intestinal wall by endometriotic lesions. The seventeenth patient refused such major surgery by laparotomy, and underwent partial laparoscopy due to the risk of bowel injury. For the 21 patients with no EUS evidence of rectal infiltration complete laparoscopic surgical exeresis was achieved in every case (100%) without broaching the intestinal wall. These preliminary results enable us to state that EUS, which is a simple and non-invasive technique, provides a reliable indication as to the presence of deep bowel infiltration in patients with retroperitoneal endometriotic lesions. EUS used pre-operatively enables patients to be selected for treatment via laparotomy or by laparoscopic surgery.

Endoscopic ultrasonography in the evaluation of pediatric digestive diseases: preliminary results

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) is rarely used in pediatrics. Its feasibility and potential indications have been assessed in this retrospective study.

PATIENTS AND METHODS

Twenty-three EUS examinations were carried out on 18 children (mean age 12 years, ranging from 4 to 16 years) using a mechanically rotating 7.5 and 12 MHz sector scan transducer. Upper digestive tract EUS (n = 17) was performed in children suffering from biliopancreatic diseases, angiomatosis or digestive tumors. They were performed under intravenous sedation. Anorectal EUS (n = 6), carried out after simple lavage in most cases, investigated tumors (adenomas and carcinoid tumor) or proctological diseases.

RESULTS

No technical failures or complications were encountered. EUS proved useful in the diagnosis of pancreatitis and portal hypertension. When included in pretherapeutic examinations, it provided useful information in cases of angiomatosis, biliary lithiasis and polyps. It was also useful in the follow-up of children after endoscopic excision or surgical treatment of adenomas or tumors (carcinoid tumor, neurofibroma).

CONCLUSION

EUS would therefore appear to be a promising technique in pediatric gastroenterology. More work is needed in order to better determine its indications and the need for equipment specific to children.

Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography

OBJECTIVE

The purpose of this study was to compare dual-phase helical CT and endosonography for the diagnosis and staging of pancreatic tumors.

SUBJECTS AND METHODS

Thirty patients with suspected pancreatic tumors underwent endosonography and dual-phase helical CT. A pathologic diagnosis was obtained in all cases with surgery (n = 23) or biopsy (n = 7), resulting in 27 neoplasms. Dual-phase helical CT and endosonographic findings were correlated with surgical and pathologic findings to determine diagnosis and resectability of pancreatic tumors.

RESULTS

Overall diagnostic sensitivity was 92% for dual-phase helical CT and 100% for endosonography (p = .45). Overall accuracy for staging of pancreatic tumors was 93% for both dual-phase helical CT and endosonography. Overall accuracy for predicting resectability was 90% for both dual-phase helical CT and endosonography. Accuracy of predicting unresectability was 100% for dual-phase helical CT and 86% for endosonography (p > .80). Differences were not considered statistically significant.

CONCLUSION

Dual-phase helical CT and endoscopic sonography do not differ significantly for diagnosis and assessment of resectability of pancreatic tumors.

Endoscopic ultrasonography in rectal linitis plastica

BACKGROUND

Rectal linitis plastica (RLP) is a rare tumor with a poor prognosis. RLP can be a primary tumor, secondary to gastric linitis, or a metastatic form of breast or prostate carcinoma. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and frequent negative biopsies (50%). The aim of this study was to evaluate the endosonographic appearance of RLP and to study the usefulness of endoscopic ultrasonography (EUS) in the follow-up of patients with RLP.

METHODS

Twenty-two video-recorded EUS examinations performed in 11 patients with histologically proven RLP were retrospectively studied. Response to conservative treatment was evaluated in three patients with secondary RLP.

RESULTS

In every case of RLP, EUS showed a circumferential thickening of the rectal wall (mean 13 mm); the thickening was mainly seen in the submucosa and the muscularis propria. In nine cases EUS showed signs of locoregional involvement (perirectal fat infiltration [n = 6], ascites [n = 5], lymph nodes [n = 3]) which was not seen by CT. In follow-up evaluations, EUS showed a lack of response to treatment in two patients with RLP secondary to gastric linitis. In the remaining patient with RLP secondary to breast carcinoma, EUS at first showed no response. The chemotherapy protocol was modified, and then improvement became evident at EUS.

CONCLUSIONS

RLP shows typical features of rectal EUS that may assist in the diagnosis of this rare disease. Moreover, EUS can be useful in evaluating the response of this disease to treatment.

Endosonographic features of esophageal granular cell tumors

BACKGROUND AND STUDY AIMS

Granular cell tumors of the esophagus are rare tumors. A definite diagnosis is achieved by endoscopic biopsies in only 50% of cases. Endoscopic ultrasonography (EUS) is the best procedure in the evaluation of upper gastrointestinal tract submucosal tumors. The aim of this study was to describe the endosonographic findings of esophageal granular cell tumors.

METHODS

From January 1989 to March 1994, 15 patients with 21 granular cell tumors which had negative biopsies were examined by EUS (Olympus GF UM3 or GF UM20,7,5 and 12 MHz). In five cases, the tumor was also studied with a 20 MHz Olympus miniprobe. The final histological diagnoses were obtained by subsequent endoscopic snare resection in 20 cases and surgically in one case.

RESULTS

The endosonographic features (with the GF UM3 or GF UM20) of esophageal granular cell tumors were: a) a tumor size of less than 2 cm in 95% of cases; b) an hypoechoic solid pattern in 100% of cases; c) a tumor arising in the inner layers in 95% (second echo-poor layer n=15; third echo-rich layer n=5). In one case, the endosonographic finding was transmural malignant infiltration of the esophageal wall (histologically confirmed).

CONCLUSION

When a granular cell tumor of the esophagus is suspected, EUS can show the inner layer location of the tumor and thus contribute to planning the endoscopic resection or follow up. When the tumor also invades the outer layers, EUS can contribute to planning the surgical resection.

Endosonographic features of pancreatic metastases

BACKGROUND

Pancreatic metastasis is a rare event. Surgical resection can provide long-term survival in selected cases. The aim of this study was to describe the endosonographic features of pancreatic metastases.

METHODS

Among the 7000 endoscopic ultrasound (EUS) examinations of the pancreas performed between 1989 and 1993, 7 were performed in patients with pancreatic metastases that were histologically confirmed (6 by surgery, 1 by CT biopsy). Videotapes of the EUS procedures were re-examined. Metastases were from four renal cell carcinomas, one ovary carcinoma, one chondrosarcoma, and one neuroendocrine carcinoma of the gallbladder.

RESULTS

A solitary lesion was imaged by EUS in six cases and 10 lesions were seen in one case. Fifteen of 16 lesions were slightly hypoechoic or isoechoic in comparison with the adjacent pancreas. They were homogeneous, round, well circumscribed and were associated with an enhancement of the ultrasonic beam. The association of these ultrasonographic patterns was different from that usually observed in cases of primary pancreatic carcinoma. In one case (ovary carcinoma), the lesion was hypoechoic, with heterogeneous infiltration and indistinct margins and with the marked attenuation of the ultrasonic beam that is commonly noticed in primary pancreatic carcinoma or in focal chronic pancreatitis.

CONCLUSION

Endosonographic features of pancreatic metastasis are usually different from those observed in cases of pancreatic carcinoma.

Interobserver agreement in endoscopic ultrasonography staging of esophageal and cardia cancer

BACKGROUND

Endoscopic ultrasonography has been accepted as an accurate means of staging cardioesophageal cancer, but no study has focused on the variability of interobserver interpretation of images so obtained.

METHODS

We compared interpretations recorded by five independent observers in 46 cases examined by endoscopic ultrasonography. One observer then reviewed a subset of 28 examinations 6 months later.

RESULTS

Interpretations were in nearly full accord for uT0 and uT4 tumors (kappa = > or = 0.73), in good accord for uT1 and uT3 tumors (kappa = > or = 0.42), but in poor accord for uT2 tumors (kappa = 0.16). Agreement was generally good when pertaining to invasion of adjacent organs, but no agreement was noted for invasion of the pericardium. In assessment of lymph node involvement, agreement was good for intra-abdominal, subcarinal, right lower paratracheal, and paraesophageal nodes (kappa = > or = 0.49), but poor for left lower and upper paratracheal lymph nodes. Intraobserver agreement was excellent for extent of tumor infiltration (kappa = 0.91) and good for lymph nodes (kappa > or = 0.51).

CONCLUSIONS

In staging cardioesophageal cancer by endosonographic ultrasonography, improvement is needed in cases of uT2 tumors and of tumors invading the pericardium, and in assessment of lymph nodes in the upper mediastinum.

[The role of ultrasonic endoscopy in the examination of post-obstetrical anal incontinence]

Echoendoscopy provides a means of exploring the anorectal and neighbouring areas. The technique has been used for over 10 years in cancerology and more recently in proctology. It can be used to confirm the anatomic integrity of the anal sphincters or to identify and localize damage, making it particularly interesting for the exploration of anal incontinence. Echoendoscopy has been used in several recent series which demonstrated that besides stretch neuropathies, defects in the sphincter play a role in post-obstetrical incontinence. Whether the signs occur early or late after menopause, these ruptures are easily identified with echoendoscopy. Thus, a reliable diagnostic of the anal lesion is possible before any therapeutic decision, not only for anal incontinence but also for prolapsus or urinary incontinence. Further prospective studies should confirm the contribution of echoendoscopy in deciding on surgical repair and help determine, and thus to prevent, the risk of sphincter rupture.

Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP

An accurate and safe preoperative method of imaging the common bile duct is essential for the proper diagnosis of calculous biliary tract disease, especially in the current era of laparoscopic cholecystectomy. The value of endoscopic ultrasonography in detecting common duct stones has been reported, albeit in small series. The aim of this retrospective study was to assess the accuracy of EUS in a large series of patients. We compared EUS to direct cholangiography in the evaluation of 422 patients for common duct stones. Ductal stones were imaged by EUS in 168 patients (43.4%). No complications were encountered. EUS failed in 2.3% of cases, ERCP failed in 8.3%, and surgical exploration failed in 0.5%. Comparison of EUS with surgical exploration in 185 patients showed a sensitivity of 94.9%, a specificity of 97.8%, and an accuracy of 95.9%. EUS was compared to ERCP in 219 patients. All common duct stones found by ERCP were evident by EUS. Concordance was obtained in 91.3% of cases. Review of videotapes disclosed 3 false-positives and 16 unequivocal true-positives. We conclude that EUS is a safe and highly accurate means of detecting common duct stones and should be proposed before laparoscopic cholecystectomy in patients at risk of choledocholithiasis.