Results Of Endoscopic Ultrasonography Research Articles

Endoscopic ultrasonography in diagnosis of duodena] cysts

Objective To investigate the diagnostic value of endoscopic ultrasonography （EUS） for duodenal cysts. Methods Clinical manifestations, results of conventional gastroscopy and EUS, as well as follow-up, of patients with duodenal cysts were retrospectively analyzed. Results A total of 105 patients with duodenal cysts presented with no lesion-related symptoms, but displayed characteristic imaging changes under EUS, which could reveal the origin, size and nature of duodenal cysts, and differentiate it from other submucosal lesions. A maximum follow-up of 5 years showed no changes in duodenal cysts. Conclusion Duodenal cyst is a benign disease, and EUS plays a very important role in diagnosis of the disease. Key words: Endoscopic uhrasonography ; Duodenal cyst ; Diagnosis ; Treatment

Endoscopic ultrasound via the esophagus: A safe and sensitive way for staging mediastinal lymph nodes in lung cancer.

Accurate, safe and fast mediastinal staging in lung cancer is pivotal to identifying patients who will benefit from surgical treatment. Imaging techniques have insufficient diagnostic power and in most cases do not abolish the need for invasive staging. A literature review using the search words "endoscopic ultrasound (EUS) and lung cancer" in PubMed was conducted. Invasive procedures (mediastinoscopy, thoracoscopy/-tomy) are the gold standard. The specificity of EUS was between 97 and 100%, and sensitivity 90 to 92%. The sensitivity was lower in studies published before 2000, and in computed tomography (CT) node-negative patients. EUS is the cheapest procedure in mediastinal staging. EUS results were associated with survival and reduced the need for invasive procedures to approximately 50% with a complication rate of approximately 0%. EUS is safe, accurate, and has a huge impact on management of mediastinal staging in lung cancer.

Is there a role for endoscopic ultrasonography in evaluation of the left liver in colorectal liver metastasis patients selected for right hepatectomy

Meticulous assessment of the left liver for patients scheduled for right hepatectomy is essential. Endoscopic ultrasonography (EUS) is frequently used for the locoregional staging or biopsy of pancreatic tumours and has shown some value in the evaluation of the left liver. We prospectively enrolled 24 consecutive patients who were scheduled for at least a right hepatectomy and who underwent laparotomy for colorectal liver metastasis (CLMs). The left liver was assessed preoperatively with standard techniques [computed tomography (CT) scan, percutaneous ultrasonography] and EUS. These results were compared with those of intraoperative ultrasonography (IOUS). The study population consisted of 12 men and 12 women (mean age 64 years, range 47-79 years). Mean body mass index was 26 kg/m(2) (range 20-35 kg/m(2)). Standard preoperative evaluation detected 28 lesions in the left liver; EUS detected just 17 lesions, whereas IOUS detected 30 lesions in the left liver. For the left lobe of the liver (segments II and III), the standard evaluation had sensitivity of 85%, specificity of 64%, positive predictive value (PPV) of 50% and negative predictive value (NPV) of 91%; EUS had sensitivity of 55%, specificity of 86%, PPV of 71% and NPV of 76%; IOUS had sensitivity of 85.2%, specificity of 92%, PPV of 96.6% and NPV of 75%. In terms of the left liver (i.e. segments II, III and IV), the results of EUS were less good than for the left lobe of the liver. For segments II and III, EUS had higher specificity and positive predictive value than standard evaluation, but only changed our therapeutic strategy in three cases. Even though EUS can provide some valuable information, the technique is not accurate enough to merit systematic performance as part of a standard preoperative evaluation. This study underlines the main role of IOUS in the left liver, with better sensitivity, specificity, and positive predictive value than EUS and standard evaluation.

Acute biliary pancreatitis: detection of common bile duct stones with endoscopic ultrasound

To determine prospectively the sensitivity and specificity of endoscopic ultrasound (EUS) for detecting common bile duct stones (CBS) in patients with acute biliary pancreatitis in whom transabdominal ultrasound was negative for CBS. In 38 consecutive patients with acute biliary pancreatitis who were negative for CBS by transabdominal ultrasound, EUS was performed before endoscopic retrograde cholangiopancreatography (ERCP). The endoscopist performing ERCP was blind to the results of EUS. The primary goal of EUS and ERCP was to confirm or exclude CBS. The reference standard for CBS was endoscopic extraction of bile duct stones after endoscopic sphincterotomy. When both procedures, EUS and ERCP excluded CBS, it was assumed that there were no CBS and endoscopic sphincterotomy was not performed. The results EUS and ERCP were compared with the McNemar test. Twenty-five of the 38 patients (66%) had CBS. EUS and ERCP were false negative in one patient each, EUS was false positive in two patients and ERCP in one patient. The sensitivity of both EUS and ERCP was 96%. The specificity of EUS and ERCP was 85 and 92%, respectively. The difference between EUS and ERCP was not significant (P=0.9). EUS proved to be as sensitive as ERCP for detection of CBS in patients with acute biliary pancreatitis. Therefore, EUS could be used as the first-line procedure in patients with acute biliary pancreatitis when therapeutic ERCP is not needed. By this approach a substantial number of unnecessary diagnostic ERCP procedures could be avoided.

The Role of Endoscopic Ultrasound for Evaluating Portal Hypertension in Children Being Assessed for Intestinal Transplantation

Intestinal transplant is an established treatment of irreversible intestinal failure, unless complicated by advanced intestinal failure-associated liver disease, when liver-bowel transplant may be necessary. Finding at least moderate hepatic fibrosis or gastroesophageal varices (GOV) at oesophago-gastroduodenoscopy (OGD) has been an indication for combined transplantation. Endoscopic ultrasound (EUS) is a sensitive method for detection of GOV. We hypothesized that EUS would detect early GOV and decrease the need for liver biopsy. Sixteen children, median age 13 months (range, 7-88), being assessed for intestinal transplant underwent simultaneous OGD and EUS. In 9 of 16 patients the results of OGD and EUS were concordant, that is, both positive (2) or both negative (7) for GOV. In seven patients, GOV were only identified by EUS. Liver biopsy was avoided in four of these cases. EUS is superior to OGD for detecting GOV in children with intestinal failure-associated liver disease and results in fewer liver biopsies being necessary.

Endoscopic ultrasound‐guided fine‐needle aspiration when combined with positron emission tomography improves specificity and overall diagnostic accuracy in unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer

The aim of this study was to assess the incremental value of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) to positron emission tomography (PET) in the diagnosis of unexplained mediastinal lymphadenopathy and staging of non-small-cell lung cancer (NSCLC). Patients who had both EUS-guided FNA and PET were retrospectively identified from an EUS database at a tertiary hospital. All EUS-guided FNA were carried out by one endoscopist between August 2002 and April 2005, either for the diagnosis of unexplained mediastinal lymphadenopathy or for the staging of NSCLC. Results of PET and EUS were compared with histology. A true histological positive result was defined as histological involvement in either surgery (mediastinoscopy or resection) or EUS-guided FNA. A true histological negative result was defined as negative involvement at surgery (mediastinoscopy or resection). Forty-nine patients who had both PET scanning and EUS-guided FNA for diagnosis of unexplained mediastinal lymphadenopathy or staging of NSCLC were identified. Of these, 33 (73% males, n = 24, age range = 44-78 years, mean = 62 years) had surgical confirmation of mediastinal lymph node pathology. In these patients, PET alone showed sensitivity, 95%; specificity, 90%; positive predictive value, 87%; negative predictive value, 90% and accuracy, 88%; whereas the addition of EUS-guided FNA increased the overall specificity and positive predictive value to 100%, with an overall accuracy of 97%. This study suggests that EUS-guided FNA complements PET by improving the overall specificity and thereby the accuracy for diagnosis of unexplained mediastinal lymphadenopathy. It provides a minimally invasive technique to assess the mediastinum in patients with NSCLC and is particularly valuable in cases in which PET findings are equivocal.

The Value of Endoscopic Ultrasonography in Predicting Resectability and Margins of Resection for Periampullary Tumors

Cure of pancreatic head and other periampullary neoplasms continues to be infrequent and is unattainable unless clear surgical margins are achieved during Whipple pancreaticoduodenectomy. Endoscopic ultrasonography (EUS) is a relatively recent gastrointestinal tumor imaging modality and may be superior to other techniques used in locoregional staging. We hypothesized that EUS can accurately predict not only tumor resectability, but also negative resection margins with Whipple resection. A retrospective review was undertaken of 81 consecutive patients with periampullary tumors who underwent preoperative CT and EUS followed by surgical exploration for intended Whipple resection. Correlations among preoperative EUS results, successful resection, and surgical margins on final histopathology were investigated. Of the 81 patients, 61 (75%) underwent successful Whipple resection, and 20 (25%) were found to be unresectable at laparotomy. Resection was achieved in 57 (86%) of 66 patients predicted to be resectable by EUS. Of the 61 resected patients, 52 (85%) had negative margins and nine (15%) had positive margins on final pathology. Margins were determined to be negative in 50 (88%) of 57 resected patients predicted to have negative margins by EUS. We conclude that EUS is a powerful and desirable imaging modality in the preoperative assessment of periampullary neoplasms.

A Randomized Prospective Trial of Endoscopic Ultrasound to Guide Combination Medical and Surgical Treatment for Crohn's Perianal Fistulas

To prospectively determine if rectal endoscopic ultrasound (EUS) can guide combination medical and surgical therapy and improve outcomes for patients with perianal fistulizing Crohn's disease. Ten patients with perianal Crohn's disease were prospectively enrolled in a randomized prospective pilot study. The patients were randomized to either the EUS cohort or the control group. All patients underwent a rectal EUS to delineate fistula anatomy followed by an examination under anesthesia by a colorectal surgeon with seton placement and/or incision and drainage, as indicated. The surgeon was blinded to the initial EUS results of patients in the control group. Medical treatment was maximized with 6-mercaptopurine (1.0-1.5 mg/kg) or azathioprine (2.0-2.5 mg/kg), ciprofloxacin (1,000 mg a day) or metronidazole (1,500 mg a day), and infliximab (5 mg/kg at 0, 2, and 6 wk and then every 8 wk). For patients in the control group, additional interventions (seton removal and repeat surgery) were at the discretion of the surgeon (without EUS guidance). Patients in the EUS cohort had EUS performed at weeks 22 and 38, with additional surgical interventions based on EUS findings. The primary end point was complete cessation of drainage at week 54. All patients had a repeat EUS performed at week 54 to determine the fistula status on EUS (secondary end point). The need for additional surgery was defined as a treatment failure. Ten patients were enrolled in the study. One of 5 (20%) in the control group and 4 of 5 (80%) in the EUS group had complete cessation of drainage. From the control group, 3 patients failed due to repeat surgery (2 for persistent/recurrent fistula and 1 for abscess), and 1 had a persistent drainage at week 54. In the EUS cohort, 1 patient had a recurrent abscess after his seton fell out prematurely. In the EUS cohort, the median time to cessation of drainage was 99 days, and the time to EUS evidence of fistula inactivity was 229 days. This pilot study suggests that using EUS to guide combination medical and surgical therapy for perianal fistulizing Crohn's disease improves the outcomes.

Clinicopathological characteristics of gastrointestinal mesenchymal tumors and diagnostic value of endoscopic ultrasonography

Gastrointestinal mesenchymal tumors (GIMTs) are tumors which arise from mesenchymal cells other than lymphocytes or epithelial cells and include gastrointestinal stromal tumors (GISTs), smooth muscle tumors, neurogenic tumors, fibroblast tumors, and liparomphalus. Here, we studied the clinicopathologic characteristics of GIMTs and determined the diagnostic value of endoscopic ultrasonography (EUS) in GIMTs. The morphological characteristics of 415 GIMT cases were observed using light microscopy. The expression of CD117, CD34, smooth muscle actin (SMA), S-100, and Ki-67 were detected using immunohistochemistry. EUS results were retrospectively analyzed in 76 cases. Among the 415 GIMT cases, there were 229 GIST cases, 178 smooth muscle tumor cases, and eight neurogenic tumor cases. Diffuse strong expression of CD117 was observed in 202 (88.2%) GISTs and strong expression of CD34 was observed in 135 (59.0%) GISTs. SMA and S-100 expression was detected in smooth muscle tumors (leiomyomas/leiomyosarcoma) and neurogenic tumors, respectively. Of the 12 cases with GISTs, nine cases with positive ki-67 expression and accompanied with more mitosis were pathologically diagnosed as malignant GISTs. Most of the borderline and malignant tumors were found in male patients. EUS was 98.7% accurate in determining GIMT locations, 82.9% accurate in diagnosing GIMTs, and 80.3% accurate in differentiating benign from malignant tumors. GISTs, rather than leiomyomas, are the most common GIMTs. Immunohistochemical markers, such as CD117, CD34, SMA, and S-100, can differentiate GISTs from smooth muscle and neurogenic tumors. The expression of Ki-67 in patients with significant karyokinesis supports a malignant tumor diagnosis. EUS is an accurate method for detecting GIMTs and differentiating between benign and malignant tumors. Use of endoscopic ultrasound-guided fine-needle aspiration biopsies may enable clinicians to make more accurate diagnoses than currently used methods.

The Utility of Endoscopic Ultrasound (EUS) in Patients with Barrett's Esophagus (BE) and High Grade Dysplasia (HGD): Analysis of the AIM Dysplasia Trial Experience

Introduction: EUS is often used in evaluating BE patients with HGD prior to treatment. Previous reports evaluating its utility in HGD have predominantly consisted of single-center studies with limited patient enrollment and have shown conflicting results. Aims: The primary aim was to assess if EUS findings alter management decisions in BE patients with HGD being considered for ablation therapy. A secondary aim was to determine the overall frequency of abnormal findings on EUS. Methods: We analyzed data from the AIM Dysplasia Trial; a randomized, sham-controlled study involving 19 US sites that evaluated radiofrequency ablation (RFA) for the treatment of BE patients with dysplasia. BE patients with HGD confirmed by a centralized expert pathology group (Cleveland Clinic(CC)) that had undergone EUS evaluation were included in the analysis. Abnormal EUS findings included the presence of submucosal invasion, nodules, and lymphadenopathy (LA). The frequency of EUS findings not visualized at endoscopy, the impact of EUS on patient management, and the frequency of complications were also assessed. Results: Of 84 patients with HGD confirmed by CC being evaluated for RFA, 62 patients with available EUS results were included in this analysis. EUS was normal in 53 (86%) patients, while abnormal findings were seen in 9 (14%) patients. These findings included the detection of esophageal nodules in 2 (3%) and LA in 7 (11%). EUS-guided fine needle aspiration (EUS-FNA) was limited to 2 patients with LA suspicious for malignancy. One showed benign cytology while the other was positive for malignant celiac and mediastinal LA from an undiagnosed lung cancer. Only 2 (3%) patients had EUS findings that were not previously identified on standard endoscopy. In one, a 7 × 7 mm esophageal submucosal nodule was seen on EUS and underwent endoscopic mucosal resection of a benign lesion. Patient management regarding ablation therapy was unaffected, as the patient was subsequently enrolled in the trial. The second was the aforementioned EUS-FNA of an undiagnosed lung cancer, resulting in trial exclusion. Finally, an attempted EUS in 1 patient was complicated by a cervical esophageal perforation that precluded further evaluation. Conclusions: In this study, the frequency of EUS findings altering management (1.6%) was equaled by the risk of a major complication. The overall frequency of abnormal EUS findings in patients with BE and HGD without mucosal defects on standard endoscopy was low, rarely altered management, and hence questions the utility of the routine use of EUS in these patients.

Role of Endoscopic Ultrasonography in Exploring the Etiology of Acute Biliary Pancreatitis with Negative MRCP Results

Objectives: To explore the role of endoscopic ultrasonography(EUS) in exploring the etiology of acute biliary pancreatitis with negative MRCP results. Methods Acute biliary pancreatitis were defined as typical pain of acute pancreatitis, serum amylase over 3 times of upper normal limit, with pancreatic parenchyma changes or surrounding exudates confirmed by CT or MRI, serum ALT over 3 times of upper normal limit. Twenty seven patients consistent with above features were enrolled from Jun 1st to Dec 31, 2006 in Changhai hospital. All the 27 patients were examined by MRCP within 7 days after the attack of the diseases with negative results. EUS were carried out within 10 days after the attack of the diseases. Results Among the 27 patients, abnormality associated with acute pancreatitis were found in 11 cases, while other 16 patients with negative EUS results. Among the 11 abnormalities, seven were biliary stones with size varing from 2 mm to 5.2 mm, two were biliary sludge, one was ampullary adenocarcina with size of 6 mm × 5 mm confirmed by subsequent EUS-FNA, one was pancreatic head duct dilated slightly with 5 mm in width with unknown causes. Conclusions The results suggest that EUS is helpful to find the etiology of acute biliary pancreatitis with negative MRCP results.

Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis

The close proximity of the echoendoscope to the extrahepatic bile ductal system and its safety make endoscopic ultrasonography (EUS) an excellent method for examining the common bile duct (CBD). The aim of the present study was to compare EUS diagnostic performance for CBD stones with endoscopic retrograde cholangiography (ERC). A prospective series of our first 60 patients (65% women, average age 43 years) who were referred for ERC for suspicion of choledocholithiasis based on clinical, biochemical and cross-sectional imaging (ultrasonography [US] or computed tomography [CT]) data underwent radial EUS. EUS results were recorded as positive or negative for CBD stones before starting the ERC. All patients underwent ERC with a balloon sweep of the bile duct as the standard of reference for CBD stone. All procedures were performed during the same endoscopy session by a single endoscopist who was blinded to the clinical, biochemical and imaging data. Sixty-five percent of our patients had low to moderate risk for CBD stones. EUS diagnoses were confirmed by ERC as follows: 23 true positive, 33 true negative, three false negative and one false positive (sensitivity of 89%, specificity of 97%, positive predictive value of 96%, and negative predictive value of 92%; overall accuracy of 93%). Compared to the EUS diagnostic accuracy (90%) during the first 30 cases, EUS had a very high diagnostic accuracy (97%) for CBD stones during the last 30 cases (P = 0.31). EUS is highly accurate for the diagnosis of choledocholithiasis. The EUS learning curve is relatively short for CBD stones.

How good is endoscopic ultrasound for TNM staging of gastric cancers? A meta-analysis and systematic review

To evaluate the accuracy of endoscopic ultrasound (EUS) for staging of gastric cancers. Only EUS studies confirmed by surgery were selected. Only studies from which a 2 x 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing and allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane control trial registry. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 x 2 tables were constructed with the data extracted from each study. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights. Initial search identified 1620 reference articles and of these, 376 relevant articles were selected and reviewed. Twenty-two studies (n=1896) which met the inclusion criteria were included in this analysis. Pooled sensitivity of T1 was 88.1% (95% CI: 84.5-91.1) and T2 was 82.3% (95% CI: 78.2-86.0). For T3, pooled sensitivity was 89.7% (95% CI: 87.1-92.0). T4 had a pooled sensitivity of 99.2% (95% CI: 97.1-99.9). For nodal staging, the pooled sensitivity for N1 was 58.2% (95% CI: 53.5-62.8) and N2 was 64.9% (95% CI: 60.8-68.8). Pooled sensitivity to diagnose distant metastasis was 73.2% (95% CI: 63.2-81.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10. EUS results are more accurate with advanced disease than early disease. If EUS diagnoses advanced disease, such as T4 disease, the patient is 500 times more likely to have true anatomic stage of T4 disease.

Detection of distant metastases in patients with oesophageal or gastric cardia cancer: a diagnostic decision analysis

Computed tomography (CT) is presently a standard procedure for the detection of distant metastases in patients with oesophageal or gastric cardia cancer. We aimed to determine the additional diagnostic value of alternative staging investigations. We included 569 oesophageal or gastric cardia cancer patients who had undergone CT neck/thorax/abdomen, ultrasound (US) abdomen, US neck, endoscopic ultrasonography (EUS), and/or chest X-ray for staging. Sensitivity and specificity were first determined at an organ level (results of investigations, i.e., CT, US abdomen, US neck, EUS, and chest X-ray, per organ), and then at a patient level (results for combinations of investigations), considering that the detection of distant metastases is a contraindication to surgery. For this, we compared three strategies for each organ: CT alone, CT plus another investigation if CT was negative for metastases (one-positive scenario), and CT plus another investigation if CT was positive, but requiring that both were positive for a final positive result (two-positive scenario). In addition, costs, life expectancy and quality adjusted life years (QALYs) were compared between different diagnostic strategies. CT showed sensitivities for detecting metastases in celiac lymph nodes, liver and lung of 69, 73, and 90%, respectively, which was higher than the sensitivities of US abdomen (44% for celiac lymph nodes and 65% for liver metastases), EUS (38% for celiac lymph nodes), and chest X-ray (68% for lung metastases). In contrast, US neck showed a higher sensitivity for the detection of malignant supraclavicular lymph nodes than CT (85 vs 28%). At a patient level, sensitivity for detecting distant metastases was 66% and specificity was 95% if only CT was performed. A higher sensitivity (86%) was achieved when US neck was added to CT (one-positive scenario), at the same specificity (95%). This strategy resulted in lower costs compared to CT only, at an almost similar (quality adjusted) life expectancy. Slightly higher specificities (97–99%) were achieved if liver and/or lung metastases found on CT, were confirmed by US abdomen or chest X-ray, respectively (two-positive scenario). These strategies had only slightly higher QALYs, but substantially higher costs. The combination of CT neck/thorax/abdomen and US neck was most cost-effective for the detection of metastases in patients with oesophageal or gastric cardia cancer, whereas the performance of CT only had a lower sensitivity for metastases detection and higher costs. The role of EUS seems limited, which may be due to the low number of M1b celiac lymph nodes detected in this series. It remains to be determined whether the application of positron emission tomography will further increase sensitivities and specificities of metastases detection without jeopardising costs and QALYs.

Quality control of endoscopic ultrasound in preoperative staging of esophageal cancer

Endoscopic ultrasonography (EUS) is generally established as the most sensitive diagnostic tool for the assessment of locoregional tumor stage in esophageal carcinoma. It therefore has a crucial impact on the decision whether patients should undergo surgery as primary treatment or should receive neoadjuvant therapy. This study retrospectively evaluates the accuracy of EUS in tumor and nodal staging of prospectively evaluated patients with esophageal carcinoma in relation to tumor type, tumor grading, tumor site, and the influence of dilation. All 214 patients included in the study underwent surgery without neoadjuvant therapy and had tumor-free resection margins with no evidence of distant metastasis. EUS investigations were done at our Department of Interdisciplinary Endoscopy. EUS results were compared with the pathological findings. EUS correctly identified T status in 141 patients (65.9 %). The sensitivity and specificity in relation to T status were 68.1 % and 98.2 % respectively for T1, 40.9 % and 83.4 % for T2, 84.3 % and 64.6 % for T3, and 14.3 % and 98.8 % for T4. The overall diagnostic accuracy of EUS in relation to N status was 64.5 % (n = 138); sensitivity and specificity for the diagnosis of N1 were 93.8 % and 20 %, respectively. Sixty-eight (80 %) of 85 pN0-staged tumors were overstaged as uN1. Dilation had a significant influence on the accuracy of EUS staging in advanced tumors ( P = 0.02), whereas tumor grading impacted on EUS staging in early tumors ( P = 0.01). Tumor site and tumor type did not show any influence. Endosonographic staging of esophageal carcinoma is still unsatisfactory. An improvement in staging accuracy may be achieved by adding fine-needle aspiration biopsy (FNA) to EUS, because FNA improves N-stage accuracy, but it has no bearing on T-stage accuracy.

Publication bias does not play a role in the reporting of the results of endoscopic ultrasound staging of upper gastrointestinal cancers

An overestimation of the accuracy of endoscopic ultrasound (EUS) results in rectal cancer staging has been reported recently, which was found to be caused by the selective reporting of more positive results. In this study, we assessed whether publication bias was also present in the reporting of EUS staging results in upper gastrointestinal cancer. A Medline literature search was performed. English-language articles containing information on the accuracy of EUS for T staging and/or N staging of esophageal, gastric, and pancreatic cancer were included. Articles published in abstract form only, case reports, and reviews were excluded. Studies reporting EUS results of patients who had undergone preoperative radiation and/or chemotherapy were also excluded. EUS results were plotted against numbers of patients, year of publication, journal type, and journal impact factor. The plots of the numbers of patients against accuracies for T stage and N stage and the statistical analyses showed no evidence of publication bias with regard to upper gastrointestinal cancer. The reported accuracy of EUS for the T stage of esophageal, gastric, and pancreatic cancer declined slightly over the years, but this was statistically significant only in the case of esophageal cancer (P = 0.01). No statistically significant correlations were found for N staging for any of the three types of cancer. In addition, no correlations were found between EUS results and journal type or journal impact factor. No evidence was found for the selective reporting of more positive EUS results for esophageal, gastric, and pancreatic cancer staging, which suggests that publication bias was not present.

Endoscopic Ultrasound: A Meta-Analysis of Test Performance in Suspected Choledocholithiasis

Objectives: To precisely estimate the diagnostic accuracy of endoscopic ultrasound (EUS) in suspected choledocholithiasis and to explore reasons for variation in diagnostic accuracy. Methods: MEDLINE and EMBASE were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable reference standard including endoscopic retrograde cholangiopancreatography, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality using validated criteria.

Clinical Correlation of Endoscopic Ultrasonography with Pathologic Stage and Outcome in Patients Undergoing Curative Resection for Gastric Cancer

Endoscopic ultrasonography (EUS) is considered valuable for preoperative staging of gastric cancer and defining patient eligibility for enrollment in neoadjuvant protocols. The aim of this study was to correlate EUS staging with pathologic evaluation and outcome in patients undergoing curative R0 resection for gastric cancer. All patients who underwent preoperative clinical assessment of T/N stage with EUS and subsequent R0 resection for gastric adenocarcinoma between 1993 and 2003 were identified from a prospective database. Patients who received neoadjuvant chemotherapy were excluded. Clinical staging results from preoperative EUS were compared with postoperative pathologic staging results and correlated with clinical outcome. Two hundred twenty-five patients with gastric cancer underwent EUS followed by R0 resection, without preoperative chemotherapy. The accuracy of the individual EUS T stage was 57% (127 of 223) and was 50% for N stage (110 of 218). Although EUS was less able to predict outcome according to individual T stage, patients with lesions <or=T2 on EUS had a significantly better outcome than patients with lesions >or=T3. Preoperative assessment of risk was not predicted by EUS N stage alone. Patients identified as high risk on EUS and those with a combination of serosal invasion and nodal disease had both the highest concordance with pathology and a significantly worse outcome (P = .02). The concordance between EUS and pathologic results was lower than expected for individual T and N stages. Patients with lesions <or=T2 had a significantly better prognosis than patients with more advanced lesions. Individual EUS N stage has limited value in preoperative risk assessment. Combined assessment of serosal invasion and nodal positivity on EUS identifies 77% of patients at risk for death from gastric cancer after curative resection.

Role of Endoscopic Ultrasound in the Diagnosis of Intraductal Papillary Mucinous Neoplasms: Correlation With Surgical Histopathology

Intraductal papillary mucinous neoplasms (IPMNs) are precancerous tumors characterized by dilation of the main pancreatic duct, its side branches, or both. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) in differentiating benign and malignant IPMNs. We identified all patients between July 1996-November 2005 who underwent preoperative EUS for IPMNs. Malignancy was defined as the presence of invasive carcinoma; all other neoplasms were considered benign. The results of EUS and EUS-guided fine-needle aspiration (EUS-FNA) were compared with corresponding histopathology. Seventy-four patients (38 male; mean age, 65 years) with 21 (28%) malignant and 53 (72%) benign IPMNs were identified. Sixty-five (88%) underwent EUS-FNA. Compared with benign tumors, patients with malignant IPMNs were more likely to be older (P = .011), present with jaundice (P = .03) or weight loss (P = .03), and have EUS features of a dilated main pancreatic duct (P = .0001), solid lesion (P = .0001), pancreatic ductal filling defects (P = .03), or thickened septa within any cyst (P = .02). The sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of malignancy were 75% (95% confidence interval [CI], 53%-89%), 91% (95% CI, 79%-97%), and 86% (95% CI, 76%-93%), respectively. Cyst or pancreatic duct fluid carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 did not differ between groups. Older age, jaundice and weight loss, and EUS features of a solid lesion, dilated main pancreatic duct, ductal filling defects, and thickened septa are predictive of malignancy in patients with IPMNs. EUS-FNA cytology is helpful, but cyst fluid CEA and CA 19-9 are of limited value to differentiate malignant from benign IPMNs.

The role of CT and endoscopic ultrasound in pre-operative staging of pancreatic cancer

Purpose The aim of our study was to compare the accuracy of computed tomography and endoscopic ultrasound (EUS) in pre-operative staging of pancreatic cancer. Methods Comparative retrospective study of 86 patients with pancreatic cancer. CT was done in 55 patients, 41 patients were examined by EUS. Each patient underwent surgery and had proven pancreatic cancer by histology. CT and EUS results were correlated to per-operative and histological findings. The main attention was paid to the description of peri-pancreatic lymphadenopathy, para-aortic lymphadenopathy, peri-coeliac lymphadenopathy and tumor relationship to superior mesenteric vein, superior mesenteric artery, portal vein, inferior caval vein and common hepatic artery. A description rate was defined as number of pre-operative findings where the structures and relationships mentioned above were described. Results The description rates of peri-pancreatic lymph nodes were 11 (20%) at CT and 36 (88.0%) at EUS. Para-aortic lymphadenopathy was described in 9 (16.0%) cases at CT and none at EUS. Peri-coeliac lymphadenopathy was mentioned only one time (2.0%) at CT contrary to 12 (29.0%) at EUS. Relationship of the tumor to the mesenteric vessels was well depicted in nine (16.0%) at CT versus nine (22.0%) at EUS. Portal vein relationship was well described in two (4.0%) at CT and seven (17%) cases at EUS. This description rate in vena cava inferior was one (2%) at CT and three (7.0%) at EUS, in hepatic artery it was one (2%) at CT and six (15%) at EUS. In the group of CT, resectability or non-resectability were well predicted in 33 (60%) patients and wrong predicted in 22 (40%) patients. In the group of EUS, resectability or non-resectability were well predicted in 34 (83%) patients and wrong predicted in 7 (17%) patients. Conclusion According to our study, EUS is more accurate in prediction of local PC resectability than CT.