Echo Endoscope Research Articles

Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound

Celiac ganglia can be visualized by endoscopic ultrasound (EUS). It is unknown how often ganglia are visualized during EUS, and what clinical factors are associated with ganglion visualization. The aim of this study was to prospectively evaluate the frequency of visualization of presumed celiac ganglia by EUS and to identify factors that predict their visualization. Clinical, demographic, EUS, and cytologic data were collected prospectively from 200 unselected patients who were undergoing EUS in a tertiary referral centre. When presumed celiac ganglia were visualized, their size, number, location, and echo features were noted. When presumed ganglia were aspirated, the results of cytology were recorded. The most common indication for EUS was investigation of a pancreatic mass or cyst (25 %). Presumed celiac ganglia were identified in 81 % of patients overall. Logistic regression analysis determined that female sex and having no prior history of gastrointestinal surgery were independently associated with ganglion visualization. Among patients whose ganglia were visualized, more ganglia were seen per patient with linear echo endoscopes (2, range 0 - 5) than with radial echo endoscopes (1, range 0 - 4) ( P = 0.001). Presumed celiac ganglia were aspirated in 10 patients; and cytologic examination revealed neural ganglia in all of these. Celiac ganglia can be visualized by EUS in most patients who undergo upper gastrointestinal EUS examinations, and are best seen with linear-array echo endoscopes. Ganglia can usually be differentiated from lymph nodes on the basis of their endosonographic appearance.

Commentaire de travail de M. Barthet et al., pp. 535

See also: EUS training in a live pig model: does it improve echo endoscope hands-on and trainee competence?Endoscopy 2007; 39(06): 535-539DOI: 10.1055/s-2007-966336

Endoscopic Ultrasound-Guided Placement of Fiducials for the Treatment of Pancreatic Cancer

Purpose: Alternative treatment options for locally unresectable pancreatic cancer are emerging. Radiosurgical therapy (Cyberknife, Accuray Inc, Sunnyvale, CA) is a new approach that allows for precise and flexible external beam radiation targeting of the tumor through an image-guided stereotactic radiosurgery system. Cyberknife treatment of pancreatic cancer requires placement of fiducial markers to enable computer tracking of the tumor during radiation delivery. This placement of the fiducial has traditionally required surgery. We present a novel technique of fiducial placement using endoscopic ultrasound.TableMethods: After informed consent, patients were given a dose of prophylactic intravenous antibiotic. Sedation was achieved in a routine fashion using intravenous midazolam and meperadine. A Pentax 5G-3630 UR radial echo endoscope was used to localize the pancreatic tumor. Next, using a Pentax 5G-3630 linear echoendoscope, one to three 5 mm gold fiducials were deployed into the center of the tumor using a Wilson Cook 19 gauge or 22 gauge EUS biopsy needle. The position of the fiducial (s) were documented by both sonography and fluoroscopy. The patients were recovered and discharged from our outpatient facility in the usual fashion. Post-implantation follow-up occurred at day # 10 during which time placement of the fiducial (s) was assessed by computed tomography. Results: Eleven patients underwent EUS-guided placement of sixteen fiducials. There were no intra-procedural complications with all patients being discharged from our ambulatory center. Upon follow-up, one patient had developed an infectious process which resolved with short-term oral antibiotics. Two patients experienced migration of their fiducials requiring repeat EUS-guided implantations without clinical consequences. All eleven patients went on to complete a 6 week course of radiosurgical therapy. Conclusions: We have shown that EUS placement of fiducials in pancreatic cancer for tumor localization can be accomplished safely and effectively. It may be an appealing alternative to conventional laparoscopic or surgical placement.

Clinical Impact of Conventional Endosonography and Endoscopic Ultrasound-guided Fine-needle Aspiration in the Assessment of Patients with Barrett’s Esophagus and High-grade Dysplasia or Intramucosal Carcinoma who have been Referred for Endoscopic Ablation Therapy

Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett's esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett's esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. Baseline pathology in the 25 patients (mean age 70, range 49-85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20%) were deemed to be unsuitable candidates for endoscopic therapy. By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.

A Single Therapeutic Echo Endoscope Used for Combined Transgastric and Transpapillary Drainage of a Pancreatic Abscess

The design of endoscopic ultrasound (EUS) instruments has been improved to provide a wide therapeutic channel and an elevator to facilitate the movement of needles and medical devices. These improvements make it possible to carry out combined ultrasound and endoscopic approaches in the pancreas and duodenal papilla, with ultrasound examination of surrounding fluid collections [1] [2] [3] [4] [5]. Cystogastrostomy is a particularly interesting field for therapeutic endosonography, with major advantages over conventional therapeutic endoscopy - including increased safety, access to distant collections, and differentiation of cystic lesions [5]. Although cystoenterostomy is an effective form of treatment, it does not provide treatment for impaired ductal drainage [3]. We report here on the use of a combined EUS and endoscopic retrograde cholangiopancreatography procedure using a single echo endoscope.

Endoscopic Ultrasonography In Portal Hypertension

Endoscopic ultrasonography (EUS) has recently emerged as an alternative means of providing data for patients with portal hypertension that is more accurate, less invasive and reproducible. It is well established that video-echo endoscopy, with combined endoscopic and sonographic examination, is comparable to endoscopy in diagnosing esophageal varices, but is more sensitive in diagnosing the presence of gastric varices. Dilated venous abnormalities outside the gastroesophageal lumen, which cannot be diagnosed by endoscopy, are readily visible by means of EUS or miniature probes. In the clinical setting of portal hypertension, endoscopic ultrasonography is also useful to predict the risk of variceal recurrence or rebleeding, which cannot be reliably predicted using endoscopy alone. The introduction of echo endoscopes equipped with Doppler facilities together with the performance of haemodynamic studies has allowed sonographic visualization of the vessels, playing thus an important role in the management of cirrhotic patients. It has thus become feasible not only to assess the vascular blood flow but also to evaluate possible morphologic and haemodynamic changes of the vessels after endoscopic or pharmacologic therapy. It is, nowadays, obvious that EUS is an exciting technological advance that has established its position in the diagnosis of varices and cirrhosis; what lies ahead for EUS is to positively find application in predicting the risk of variceal bleeding and in managing portal hypertension.

Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer

To evaluate the value of endoscopic ultrasonography (EUS) in the preoperative TNM staging of gastric cancer. Forty-one patients with gastric cancer (12 early stage and 29 advanced stage) proved by esophagogastroduodenoscopy and biopsies preoperatively evaluated with EUS according to TNM (1997) classification of International Union Contrele Cancer (UICC). Pentax EG-3630U/Hitachi EUB-525 echo endoscope with real-time ultrasound imaging linear scanning transducers (7.5 and 5.0 MHz) and Doppler information was used in the current study. EUS staging procedures for tumor depth of invasion (T stage) were performed according to the widely accepted five-layer structure of the gastric wall. All patients underwent surgery. Diagnostic accuracy of EUS for TNM staging of gastric cancer was determined by comparing preoperative EUS with subsequent postoperative histopathologic findings. The overall diagnostic accuracy of EUS in preoperative determination of cancer depth of invasion was 68.3% (41/28) and 83.3% (12/10), 60% (20/12), 100% (5/5), 25% (4/1) for T1, T2, T3, and T4, respectively. The rates for overstaging and understaging were 24.4% (41/10), and 7.3% (41/3), respectively. EUS tended to overstage T criteria, and main reasons for overstaging were thickening of the gastric wall due to perifocal inflammatory change, and absence of serosal layer in certain areas of the stomach. The diagnostic accuracy of metastatic lymph node involvement or N staging of EUS was 100% (17/17) for N0 and 41.7% (24/10) for N+, respectively, and 66% (41/27) overall. Misdiagnosing of the metastatic lymph nodes was related to the difficulty of distinguishing inflammatory lymph nodes from malignant lymph nodes, which imitate similar echo features. Predominant location and distribution of tumors in the stomach were in the antrum (20 patients), and the lesser curvature (17 patients), respectively. Three cases were found as surgically unresectable (T4 N+), and included as being correctly diagnosed by EUS. EUS is a useful diagnostic method for preoperative staging of gastric cancer for T and N criteria. However, EUS evaluation of malignant lymph nodes is still unsatisfactory.

Use of the Curved Linear-Array Echo Endoscope to Identify Gastrorenal Shunts in Patients with Gastric Fundal Varices

We read with interest the article by Kakutani et al. reporting on the value of echo endoscopy for detecting and identifying gastrorenal shunts in patients presenting with gastric fundal varices [1]. The authors note that balloon-occluded retrograde transvenous obliteration has been described as effective in patients with bleeding fundal varices. This treatment modality requires a spontaneously developed gastrorenal shunt as a pathway for the balloon catheter to reach the fundal varices. The authors suggest that the curved linear-array echo endoscope can be used to assess whether a gastrorenal shunt is present, and compared this method with contrast-enhanced computed tomography.

Endoscopic Ultrasound-Guided Drainage of Pancreatic Pseudocysts Complicated by Portal Hypertension or by Intervening Vessels

Portal hypertension often coexists with pancreatic pseudocysts and is potentially dangerous if a collateral vessel is in the vicinity of the needle puncture pathway. Hitherto, there have been no reports of pseudocyst drainage in this setting. Patients who underwent endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage complicated by intervening vessels were assessed for success and outcomes. An Olympus mechanical linear-array video echo endoscope GF-UM 140D was used for the drainage procedure in all patients. Either a "hot" diathermy technique was employed or a "cold" technique using direct aspiration with a 19-G needle, followed by deployment of a nasocystic catheter. Eight patients with a symptomatic pseudocyst and intervening vessels underwent drainage that was guided (n = 6) or assisted (n = 2) by EUS. All were found to have successful resolution of the cyst at follow-up 6 weeks later, while segmental portal hypertension had disappeared in one patient. There were no major complications. One patient had transient hemorrhagic drainage that resolved by itself. Pseudocysts complicated by portal hypertension or by intervening vessels can be safely drained under EUS guidance, even in the absence of color Doppler imaging.

Frequency and Costs of Echo Endoscope Repairs: Results of a Survey of Endosonographers

The need for repair of endoscopic ultrasound (EUS) equipment appears to be frequent and expensive. To better quantify the costs associated with echo endoscope failure, a survey of endosonographers was carried out. A survey questionnaire concerning echo endoscope damage and repair and consequences of echo endoscope downtime over a 12-month period was sent to members of the American Society of Gastrointestinal Endoscopy who had cited an interest in EUS. Responses were received from 56 of 138 institutions where EUS was carried out (41 %). A median of 325 EUS procedures had been carried out in the past year and a median of two endosonographers were employed who used an average of three echo endoscopes. Two-thirds of institutions trained fellows. A total of 225 repairs were reported for leaks (47 %), mechanical failures (33 %), images or optics difficulties (26 %), or other problems (1 %). Mechanical radial-scanning echo endoscopes tended to break, on average, after 68 procedures, while curved linear-array echo endoscopes failed after an average of 107 procedures. Echo endoscope failures led to rescheduling of procedures at three-quarters of institutions. Institutions paid an average of $ 10 534 over 12 months for echo endoscope repairs. The average repair cost per procedure was $ 41. There was an inverse relationship between quantity of procedures and the per-procedure repair rate ( P < 0.05). Direct and indirect costs of echo endoscope repairs are significant. Instrument failures are multifactorial; however instrument complexity, instrument age, and institutional inexperience may contribute to repair costs.

Pancreatic Endosonography after Billroth II Gastrectomy

Prior Billroth II gastrectomy is considered a relative contraindication to endoscopic ultrasonography (EUS) of the pancreatic head. This study reviews experience with pancreatic EUS in such patients. Eleven patients were identified who had previous Billroth II gastrectomy and underwent attempted pancreatic EUS. Examination of the pancreatic head was technically feasible in 10 of the patients. The inferior pancreatic head, ampulla, and periampullary ducts were seen in all; the superior pancreatic head and porta hepatis were visualized in 50 % of cases with radial echo endoscopes and 100 % with a linear-array echo endoscope. The pancreatic neck was fully imaged in 25 % of cases with radial echo endoscopes and in 60 % with a linear-array echo endoscope. One known pancreatic neck mass was not visualized. Pancreatic EUS is technically feasible in most patients with a prior Billroth II gastrectomy. Linear-array echo endoscopes provide a more complete examination than radial echo endoscopes. The pancreatic neck may be difficult to visualize.

Endosonography Versus Helical Computed Tomography for Locoregional Staging of Gastric Cancer

Endosonography (EUS) has been shown to be more accurate than incremental computed tomography (CT) in the local (T) and regional (N) staging of gastric carcinoma; however, EUS has never been compared with helical CT (HCT). The fifth edition of the TNM classification changed the guidelines for N-staging of gastric carcinoma. The accuracy of imaging methods in this new system remains unknown. Staging accuracy of EUS and HCT were compared prospectively with pathological or intraoperative findings in 88 gastric carcinoma patients. Staging was done according to the fourth and fifth editions of the TNM classification. EUS was done with a radial echo endoscope, and HCT with a scanner with two rows of detectors (two-phase contrast-enhanced scanning of a water-filled stomach). The T-staging accuracy of EUS (63 %, CI 52 - 73 %) was superior to the accuracy of HCT (44 %, CI 34 - 55 %; P = 0.021). N-staging accuracy of both methods was similar when the fourth edition of the TNM classification was used (EUS 47 %, CI 34 - 60 %; HCT 52 %, CI 38 - 65 %). However, HCT was more accurate than EUS when the fifth edition of the classification was applied (EUS 30 %, CI 18 - 43 %, HCT 47 %, CI 34 - 60 %; P = 0.044). The accuracy of detection of lymph node metastases was similar for both methods (EUS 67 %, CI 54 - 78 %; HCT 77 %, CI 64 - 86 %). EUS is more accurate than HCT in the T-staging of gastric carcinoma. Both methods are comparable for N-staging, when this is done according to the older, fourth edition of the TNM classification. If the fifth edition is used, EUS is less accurate than HCT.

One Step Endoscopic Drainage of Pancreatic Pseudocysts: Use of a New Therapeutic Echo Endoscope

Background: Different methods have been proposed for pancreatic pseudocysts (PPC) drainage. We describe our experience in endoscopic drainage of PPC with a one step technique using a new therapeutic echo endoscope with a linear curved array transducer, a 3.7 mm working channel and an elevator (Olympus GF-UCT140-AL5). Methods: 12 patients (8 men, 4 women; mean age 53.9, range 28-77) were referred from October 2002 to October 2003 for endoscopic pseudocyst drainage. The mean size of the pancreatic cysts was 11.2 cm (6.5-25 cm). Either monitored anesthesia with Propofol or general anesthesia was used to sedate the patients. The Olympus GF-UCT140-AL5 was passed into the stomach; the optimal localization of the puncture site was determined. Color Doppler was used to rule out gastric varices and large vessels. Under real time ultrasound guidance a 19 gauge FNA needle (EchoTip, Wilson-Cook) was then inserted into the pseudocyst. A 0.025″ Jagwire (Boston Scientific) was passed through the needle under fluoroscopy and coiled into the pseudocyst. A Needle Knife (HPC-3) was introduced over the wire. Under EUS and endoscopic guidance an electrosurgical puncture was performed using the Needle Knife. The tract was dilated with a 10 mm balloon followed by the placement of 1 to 3 10-Fr double pigtail stents. The stents were removed in 1 to 3 months after the resolution of the cyst. Results: Drainage was not attempted on 2 patients due to large gastric varices on the first and a malignant mass in the cyst of the second, both diagnosed only by EUS. Drainage was attempted on 10 patients; placement of the 10-Fr double pigtail stents was successful in 9 patients. In one case drainage could not be achieved. In one other patient with a large cyst and internal debris surgery was required for a cyst infection that did not resolve with endoscopic management. 8/10 patients had complete resolution of their symptoms and cysts. One patient required 2 procedures due to the presence of debris in the cyst. There were no significant bleeding or other complications noted. Conclusion:In our experience EUS is essential prior to endoscopic drainage of PPC as it affected the clinical management of 2/12 patients. Endoscopic drainage of PPC using the new therapeutic echo endoscope with EUS guided wire placement and puncture allows a safe one step procedure without exchanging scopes.

EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology.

Despite improvements of diagnostic modalities differentiation between benign and malignant hilar strictures remains a challenge. Hilar neoplasia requires preoperative tissue diagnosis to avoid risk of inappropriate extensive surgery. This is commonly attempted using various techniques at ERCP, which have variable sensitivity and accuracy. We used endosonography-guided fine-needle aspiration (EUS-FNA) for the preoperative diagnosis of hilar cholangiocarcinoma (HC). Prospective evaluation of 44 patients (31 male, mean age: 59 yr) with strictures at the liver hilum were diagnosed by CT and/or ERCP. All were suspicious of HC but had inconclusive tissue diagnosis. They underwent EUS-FNA with linear echo endoscope and 22 gauge needles. Adequate material was obtained in 43 of 44 patients. Cytology revealed HC in 26 and other malignancies in 5 patients; 12 had benign results: sclerosing cholangitis (n = 4), primary sclerosing cholangitis (n = 4), inflammation (n = 3), sarcoid-like lesion (n = 1). There were no significant differences in age, lesion size, or echo features among patients with adenocarcinomas, other malignancies, or benign lesions. Thirty-two patients underwent surgery, 2 had autopsy, 10 were followed up clinically. Four of the benign results were false negatives. No complications occurred. Accuracy, sensitivity, and specificity were 91%, 89%, and 100%, respectively. EUS and EUS-FNA changed preplanned surgical approach in 27 of 44 patients. These results suggest that EUS-FNA is of value as a new, less-invasive approach for tissue diagnosis of hilar strictures of unknown cause. It was technically feasible without significant risks, when other diagnostic tests were inconclusive and was able to change preplanned management in about half of the patients.

Prevalence and significance of periduodenal venous collaterals in patients evaluated for pancreaticobiliary disorders by endosonography.

The prevalence of periduodenal venous collaterals detected by endoscopic ultrasonography (EUS) in patients undergoing evaluation for pancreaticobiliary disorders, and their influence on the success of transduodenal fine-needle aspiration (FNA) of solid pancreatic masses is not known. Records for all consecutive patients who underwent EUS for pancreaticobiliary disorders over a 14-month period were reviewed. EUS was carried out by a single endosonographer using a radial echo endoscope. When FNA was attempted, a curvilinear-array echo endoscope was used in conjunction with color flow Doppler. Periduodenal and perigastric collaterals were defined as multiple anechoic serpiginous structures imaged from the duodenal bulb, the second portion of duodenum, or the stomach. Established criteria were used to assess the presence of chronic pancreatitis. Over the study period, 338 patients (mean age 58.9 +/- 14.5 years; 52 % women) underwent EUS for pancreaticobiliary disorders. Periduodenal collaterals were detected in 22 patients (6.5 %), 21 of whom (19 %) had pancreatic cancer. Patients with pancreatic cancer were significantly more likely to have periduodenal collaterals in comparison with those without pancreatic cancer (OR 25; 95 %CI, 5.75 - 109; P = 0.001). Computed tomography detected collaterals in only two of the 22 patients (9.1 %). Periduodenal collaterals made transduodenal FNA impossible in nine of the 22 patients (41 %). However, in these patients a cancer diagnosis was obtained using EUS-FNA from liver lesions in two cases; using a transgastric approach in two (pancreatic neck lesions); and atypical cells were obtained in two. A safe window could not be achieved in three patients (13.6 %). Transduodenal FNA was performed by avoiding the collaterals and was successful in 13 of the 22 patients, with no bleeding complications. Periduodenal collateral vessels are infrequent in patients with suspected pancreaticobiliary disease, but are relatively common in patients with pancreatic cancer. Transduodenal EUS-FNA can be carried out safely in the majority of cases in the presence of periduodenal collaterals, but collaterals may occasionally hamper successful transduodenal pancreatic FNA.

Drainage of deep pelvic abscesses using therapeutic echo endoscopy.

The purpose of this study was to evaluate the clinical efficacy of endosonographically guided transrectal aspiration and drainage by plastic stent of deep pelvic abscesses, using a therapeutic echo endoscope device. Between September 2000 and June 2001, 12 patients (nine men, three women, mean age 67 years) were treated for a perirectal or a pelvic abscess using an endoscopic ultrasound (EUS) technique. The drainage of these fluid collections was performed under EUS guidance, using therapeutic EUS scopes with a large working channel. No major complication occurred during this study. Transrectal stent insertion succeeded in nine patients. In three patients, only aspiration was possible. Among the nine patients in whom a stent was successfully introduced into the fluid collection, complete drainage without relapse was achieved in eight patients (mean follow-up 10.6 months, range 6-14 months). The stent was removed endoscopically after 3 to 6 months. Drainage was incomplete in one patient (with a large abscess, diameter > 8 cm), who subsequently underwent surgical drainage. However, two out of the three patients in whom aspiration alone was performed developed a recurrence of the abscess and required surgical treatment. EUS-guided drainage of deep pelvic abscesses could offer an alternative treatment to surgery in the management of these postoperative complications.

Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis

OBJECTIVES: The clinical value of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic lesions is uncertain in patients with normal parenchyma and chronic pancreatitis. The aim of this study was to analyze the diagnostic yield and influence of EUS-FNA on the clinical management of patients with pancreatic lesions, in the presence (CP) or absence (NP) of chronic pancreatitis. METHODS: A total of 207 consecutive patients with NP (n = 133) and CP (n = 74) were examined using linear array echo endoscopes for the procedure and 22-gauge needles. RESULTS: Adequate specimens were obtained from 200 lesions. A correct final diagnosis was established at histology (n = 108), bacteriology (n = 9), and clinical follow-up (n = 83). Cytology gave 17 false-negative EUS-FNA results (overall sensitivity: 85%). In patients with NP, 60 solid adenocarcinomas were detected, 32 other malignancies, and 38 benign lesions, with 11 false-negative results (sensitivity: 89%). In patients with CP, only seven of 13 malignancies (all solid adenocarcinomas) were identified using FNA (sensitivity: 54%). Overall, malignancy was identified in 116 patients, 32 of whom (27%) had lesions other than primary solid adenocarcinomas. Management was altered in 25 of these patients, which changed the surgical approach in 21%. EUS-FNA influenced the therapeutic approach in 44% of the total patient group. CONCLUSIONS: EUS-FNA was especially useful in patients with a focal pancreatic lesion with normal parenchyma. Its sensitivity in patients with CP was unacceptably low, and resection of the tumor using standard surgical techniques was still usually required to confirm the correct diagnosis. Diagnostic EUS-FNA influenced clinical management in nearly half of patients.

Length of esophageal cancer and degree of luminal stenosis during upper endoscopy predict T stage by endoscopic ultrasound.

Endoscopic ultrasonography (EUS) is considered to be the most accurate modality for T staging of esophageal cancer. This study attempted to determine whether endoscopic features such as the length and degree of luminal stenosis in esophageal cancer can predict the T stage on EUS. Thirty-five patients with newly diagnosed esophageal adenocarcinoma or squamous-cell carcinoma undergoing EUS prior to initiation of any treatment were included in the study. The length of the tumor was assessed prospectively during esophagogastroduodenoscopy (EGD) before EUS in 22 patients. Radial EUS was then performed in these patients. The other 13 patients had sufficient luminal stenosis to prevent complete advancement of the echo endoscope through the tumor. In these 13 patients, the length of the esophageal cancer was not examined, but the T and N stage up to the level of maximum advancement of the echo endoscope through the tumor were noted. All 13 patients with luminal stenosis had at least a T3 (n = 12) or T4 (n = 1) lesion up to the level of maximum advancement of the echo endoscope. Among the 22 patients in whom the length of the esophageal cancer was measured, the mean length in the 13 patients with a T1 or T2 lesion on EUS was 2.6 cm. The mean length in the nine patients with T3 esophageal cancer was 7.1 cm. The difference in the mean length of T1 or T2 lesions (2.6 cm) was significantly different ( P < 0.001) from the mean length of T3 lesions (7.1 cm). Using a clinical diagnostic testing approach, when > or = 5 cm length was used as a criteria for diagnosing T3 lesions, the sensitivity was 89 %, specificity 92 %, positive predictive value 89 %, and negative predictive value 92 %. There was also a suggestion of increased chances of lymph-node metastases with increasing length of esophageal cancer. In esophageal carcinoma, endoscopic features such as the length of the cancer and the degree of luminal stenosis correlate with T staging on EUS. Esophageal cancers that are > or = 5 cm in length, or are sufficiently stenotic to prevent passage of an endoscope, are much more likely to be T3 or higher-stage lesions, while those that are < 5 cm in length have a greater chance (92 %) of being T1 or T2.

Transmural drainage of cystic peripancreatic lesions with a new large-channel echo endoscope.

The availability of a new large-channel echo endoscope led us to develop a new needle-stent device for endoscopic puncture and drainage of pancreatogenic cystic lesions. The purpose of this study was to examine whether endoscopic ultrasound (EUS)-guided one-step 10-F puncture and drainage with the new equipment could be feasible and successful. The use of the technique and the short-term outcome in our first four patients are described and discussed. Cystic lesions were drained using the new technique in four patients. All the patients had symptomatic peripancreatic lesions, one with intrahepatic and one with intrasplenic extension. Punctures were carried out using a new echo endoscope with a 3.7 mm working channel and an Albarran lever. The 10-F transmural stents were placed over a 1 mm stainless steel needle and a 6-F Teflon catheter using a special assembly designed for controlled one-step placement and stent release. Puncture and drainage were technically successful in two patients. In one patient, the 10-F component failed to pass the cystic wall. Drainage was successful in the same session using a 7-F one-step device. In one patient, no stent was placed, but the 1 mm needle was used for diagnostic tissue sampling during the procedure because of the suspicious cyst morphology. Surgical resection revealed a ganglioneuroma. The new echo endoscope allows endoscopic interventions for peripancreatic cystic lesions under excellent endoscopic and EUS control. The Albarran lever was reliable and helpful for optimal direction of the needle. The new echo endoscope combined with special needle-stent devices was effective and safe for diagnosis and therapy in the first four cystic lesions. Cystic tumors must always be considered as a differential diagnosis in patients with apparently pancreatitis-induced cystic lesions.

Endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) cytology for diagnosis of chronic pancreatitis.

Previous studies have shown that endoscopic ultrasonography (EUS) sensitively detects morphologic abnormalities due to chronic pancreatitis. However, morphologic EUS findings have limited specificity, particularly at the early stages of chronic pancreatitis. Our aims were to study pancreatic morphology and inflammation in patients with chronic pancreatitis, using EUS and fine-needle aspiration cytology (EUS-FNA), and to compare the results with those of endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic function tests. 37 patients (48 +/- 13 years) with clinical symptoms and laboratory test findings suggestive of chronic pancreatitis were prospectively studied. Patients with malignancy or major concomitant disorders were excluded. Clinical evaluation included indirect pancreatic function tests. Morphologic criteria for chronic pancreatitis included echo-intense septae/echo-reduced foci (i. e. pseudolobularity), ductal irregularities, and calcifications. EUS-FNA was performed in 27/37 patients, by means of the Hitachi FG34-UX echo endoscope and a 22-gauge needle, and tissue specimens were submitted for standard cytological evaluation. ERCP served as reference in all patients, using the Cambridge classification. 31 patients had chronic pancreatitis while six had normal findings at ERCP. EUS showed morphologic abnormalities of the pancreas in 33 patients. Morphologic abnormalities alone reached a sensitivity of 97 % for chronic pancreatitis with a specificity of only 60 %, while the positive predictive value (PPV) was 94 %, and the negative predictive value (NPV) was 75 %. EUS-FNA increased the negative predictive value to 100 % and the specificity to 67 %. On average, 2.3 needle passes were necessary to obtain sufficient amounts of tissue. The correlation of EUS findings with pancreatic function tests was poor. EUS results were in agreement with regard to the severity of chronic pancreatitis in 5/8 patients with grade I disease, in 11/13 patients with grade II, and in 10/10 patients with grade III disease. Minor complications occurred in two patients (7 %). EUS is as sensitive and effective as ERCP in the detection of chronic pancreatitis, particularly when only mild disease is present. However, EUS findings have limited specificity, particularly in patients with mild disease. EUS-FNA with cytology is safe and improves the negative predictive value. Negative EUS-FNA findings rule out chronic pancreatitis, but cytological investigation alone does not improve the specificity of EUS findings, suggesting that further improvements in tissue sampling and analysis are necessary to support routine use of FNA in patients with chronic pancreatitis.