Endoscopic Ultrasound Group Research Articles

Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low‐grade dysplasia

BackgroundThe accurate diagnosis of dysplasia or carcinoma within ampullary lesions can be difficult, but, when possible, identifies patients who require endoscopic or surgical resection, respectively. The role of endoscopic ultrasound (EUS) in diagnosing these lesions and the degree of dysplasia is unclear. MethodsPatients with lesions of the ampulla were identified over 5 years. Patients who did not undergo EUS were compared with those who did. ResultsA total of 27 of 58 (47%) patients were investigated with EUS. Pretreatment diagnoses were correct in 93% of the EUS group vs. 78% of the no‐EUS group. Rates of diagnostic accuracy in low‐grade dysplasia (LGD), high‐grade dysplasia (HGD) and adenocarcinoma (ADC) were 72%, 20% and 96%, respectively, in the no‐EUS group, and 93%, 50% and 100%, respectively, in the EUS group. Every diagnosis of LGD in the EUS group was correct, whereas these diagnoses accounted for the majority of errors (eight of 13) in the no‐EUS group. High‐grade dysplasia was frequently misdiagnosed. More patients were treated by endoscopic resection in the EUS group (12 of 27 vs. five of 31; P= 0.025). ConclusionsEndoscopic ultrasound increases the accuracy of preoperative diagnosis of ampullary lesions and is particularly useful in patients with LGD because it permits safe endoscopic management. Patients with HGD must be reviewed carefully and considered for pancreatoduodenectomy.

Endosonography and magnetic resonance cholangiopancreatography show similar efficacy in selecting patients for ERCP in mild-moderate acute biliary pancreatitis

We aimed to compare the value of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in identifying the patients with mild-moderate acute biliary pancreatitis who require endoscopic retrograde cholangiopancreatography. The study was prospectively conducted in a tertiary hospital between June 2006 and October 2009. Ninety-five patients without urgent endoscopic retrograde cholangiopancreatography requirement and with mild-moderate acute biliary pancreatitis were included in the study. Patients whose amylase, C-reactive protein, and bilirubin levels had decreased more than 50% on the fifth day compared to admission levels were randomized to magnetic resonance cholangiopancreatography or endoscopic ultrasonography, and the common bile duct was evaluated. Endoscopic retrograde cholangiopancreatography was performed in patients with stone detected with endoscopic ultrasonography or magnetic resonance cholangiopancreatography. With regard to the presence of common bile duct stone in endoscopic retrograde cholangiopancreatography, endoscopic retrograde cholangiopancreatography performances were classified as therapeutic or diagnostic. Endoscopic retrograde cholangiopancreatography was performed in 16 of the 48 patients (33.3%) in the endoscopic ultrasonography group and in 18 of the 47 patients (38%) in the magnetic resonance cholangiopancreatography group. Therapeutic endoscopic retrograde cholangiopancreatography was performed in 14/16 patients (87%) in the endoscopic ultrasonography group and in 16/18 patients (88%) in the magnetic resonance cholangiopancreatography group. The ratio of total number of endoscopic retrograde cholangiopancreatographis was not significantly lower in the endoscopic ultrasonography (16/48) than in the magnetic resonance cholangiopancreatography (18/47) group, and the ratio of therapeutic endoscopic retrograde cholangiopancreatographis (14/16) was not higher in the endoscopic ultrasonography group than in the magnetic resonance cholangiopancreatography group (16/18). The necessity of therapeutic endoscopic retrograde cholangiopancreatography was determined with similar efficacy by endoscopic ultrasonography and magnetic resonance cholangiopancreatography in mild-moderate acute biliary pancreatitis.

Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis

Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis

Outcomes after preoperative endoscopic ultrasonography and biopsy in patients undergoing distal pancreatectomy

This retrospective cohort study analyzes the potential risks associated with preoperative fine needle aspiration (FNA) biopsy guided by endoscopic ultrasonography (EUS) in patients undergoing distal pancreatectomy. Excluding 204 patients with acute or chronic pancreatitis and those with previous pancreatic resections, 230 consecutive patients with primary pancreatic neoplasms underwent elective distal pancreatectomy between 2002 and 2009. The most common indications were adenocarcinoma (28%), intraductal papillary mucinous neoplasm (IPMN; 20%), and endocrine neoplasms (17%). Two-way statistical comparisons were performed between patients who did (EUS(+)) or did not (EUS(-)) undergo preoperative EUS-FNA. Distal pancreatectomy was performed open in 118 patients (56%) and laparoscopically in 102 patients (44%). No differences were observed in age, sex, American Society of Anesthesiologists class, operative time, or blood loss between the EUS(+) (n = 179) and EUS(-) (n = 51) groups. Splenectomy was performed in 162 patients (70%) and was more common in the EUS(+) group. With the exception of adenocarcinoma (n = 57 [32%] EUS(+) vs n = 6 [12%] EUS(-); P < .01), the final pathologic diagnosis did not differ significantly between the EUS groups. Postoperative complications were more common in the EUS(+) patients with cystic neoplasms (43% vs 16% EUS(-); P = .04). EUS-FNA caused pancreatitis in 2 patients preoperatively. No differences in overall or recurrence-free survival were noted between cancer patients in the EUS groups. Patterns of tumor recurrence were not associated with EUS-FNA. Preoperative EUS-FNA is not associated with adverse perioperative or long-term outcomes in patients undergoing distal pancreatectomy for solid neoplasms of the pancreas. The potentially detrimental long-term impact of preoperative EUS-FNA in patients with resectable pancreatic adenocarcinoma was not observed, but will require additional study.

A Retrospective Study of Pancreatic Pseudocyst Management

Purpose: Pancreatic pseudocysts (PP) can be managed by surgery, EUS (endoscopic ultrasound) and CT-guided drainage. There is scant data on the clinical outcomes and the cost of these three procedures. Aim: To study the characteristics of clinical outcomes concerning EUS, Surgical and CT guided techniques of PP drainage, and associated direct cost of hospitalization. Methods: Chart review by searching UMass Memorial Medical Center database between June 2005 and April 2011 was done for all patients with PP who had drainage. Patients were classified on basis of initial procedure. Main outcome is treatment success which was defined as complete resolution or decrease in size of PP to 2 cm, in association with clinical resolution of symptoms at 6 week follow up. Re-intervention was defined as need for repeated procedure because of persistent symptoms with a residual PP more than 4 cm. Direct cost in U.S. dollars included all charges for hospital stay from day of admission to discharge. Results: 58 patients were identified, 19, 31 and 8 patients in EUS, CT and Surgery groups. Clinical characteristics are described in Table 1. CT guided group is slightly older than 2 groups p = 0.02. Albumin level in surgical group is slightly lower than other 2 groups p = 0.03. Mean WBC count is similar for all three groups p = 0.12. Treatment success rate was 74%,54%,62% in EUS, CT and surgical groups respectively p = 0.013. Treatment success rate is highest in PP located in the head and lowest in body there is no statistical difference chi = 7.37 p = .117. Success rate of tail PP drainage in EUS group was 83.3%. Reintervention rate was 36%,33%,50%, in EUS, CT, and surgery groups respectively. Complications were observed in 31%, 12% and 25% in EUS, CT and surgical groups respectively. Total length of stay was significantly different in the three groups 12, 31 and 56 days in EUS, CT and surgery groups respectively. Average cost of hospital stay for patients in EUS group $91186 was less when compared with CT groups $279393 and surgical $458455 p<0.0001.Table 1: . No Caption available.Conclusion: This study shows reasonable success rates in all three modalities when compared to recent studies. EUS guided drainage is increasingly accepted as an initial step in management considering success rate, cost and complications obviating the need for surgery. On average, length of hospital stay and associated cost for patients who were admitted and had PP drainage is very high, which were due to multiple co-morbidities. Major study limitation is lack of stratification based on severity of condition and underlying co-morbidities. A large randomized study is needed to better evaluate and compare costs and outcomes of these three modalities.Table 2: . No Caption available.

Clinical evaluation of endoscopic ultrasonography and CT in the prediction of the resectability of esophageal carcinoma

To evaluate the role of endoscopic ultrasonography (EUS) and CT in the prediction of the resectability of esophageal carcinoma. A retrospective study was carried out in 746 patients with esophageal carcinoma. These patients were divided into CT group (480 cases), EUS group (151 cases) and EUS+CT group (115 cases). Images of EUS and CT were double-blindly reviewed by radiologists. Relationship of EUS and CT images with surgical and pathological findings was examined. Resection rates in the EUS group, CT group and EUS+CT group were 93.4%, 91.0% and 93.9%, respectively (chi(2)=1.551, P=0.484). Accuracy, sensitivity, specificity, positive predictive value and negative predictive value in the CT group were 81.7%, 87.4%, 23.3%, 92.0% and 15.4%, respectively; 94.7%, 98.6%, 40.0%, 95.9% and 66.7% in the EUS group; and 96.5%, 99.1%, 57.1%, 97.3% and 80.0% in the EUS+CT group, respectively. When assessing aortic invasion, accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 91.3%, 33.3%, 93.1%, 13.5% and 97.7%, in the CT group, respectively; 98.7%, 87.5%, 99.3%, 87.5% and 99.3% in the EUS group, respectively,and 98.3%, 85.7%, 99.1%, 85.7% and 99.1% in the EUS+CT group, respectively. In assessing tracheobronchial invasion, accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 91.3%, 20.8%, 95.0%, 17.9% and 95.8% in the CT group, respectively; 96.0%, 20.0%, 98.6%, 33.3% and 97.3% in the EUS group, respectively; and 98.3%, 66.7%, 99.1%, 66.7% and 99.1% in the EUS+CT group. Differences in assessing resectability were significant between CT group and EUS group (chi(2)=15.131, P=0.000), between CT group and EUS+CT group (chi(2)=15.662, P=0.000), and between EUS group and EUS+CT group (chi(2)=0.502, P=0.346). Differences in assessing aortic invasion were significant between CT group and EUS group (chi(2)=9.764, P=0.000), and between CT group and EUS+CT group (chi(2)=6.659, P=0.004), but were not significant between EUS group and EUS+CT group (chi(2)=0.076, P=0.581). Differences in assessing tracheobronchial invasion were significant between CT group and EUS+CT group (chi(2)=6.659, P=0.004), but were not significant between CT group and EUS group (chi(2)=3.729, P=0.034) and between EUS group and EUS+CT group (chi(2)=1.117, P=0.248). EUS is a better procedure than CT in the prediction of the resectability and aortic invasion in esophageal carcinoma. There is limited value for EUS and CT in assessing tracheobronchial invasion. Combination of CT and EUS does not improve the prediction of resectability significantly.

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.

Impact of Preoperative Endoscopic Ultrasound on Non-small Cell Lung Cancer Staging

To determine if the addition of preoperative endoscopic ultrasound (EUS) to non-small cell lung cancer staging can reduce the proportion of patients in whom malignant mediastinal lymph nodes (inoperable disease) are discovered at surgery. All patients with lung cancer who underwent mediastinoscopy or thoracotomy for cancer diagnosis, staging, or treatment from 1999 to 2005 were identified. Patients who had undergone preoperative EUS were designated as the EUS group. The control group was composed of similar patients who had not undergone preoperative EUS, and were frequency matched to those in the EUS group in a 3:1 ratio by preoperative cancer stage. The proportion of patients in whom malignant mediastinal lymph nodes were diagnosed at surgery was the primary outcome. Forty-four patients (average age, 67.8 years) met criteria for the EUS group, and 132 patients (average age, 67.4 years) were selected as control subjects. Overall, in the EUS group, 3 of 44 patients (6.8%) were found to have malignant mediastinal lymph nodes at surgery, compared with 41 of 132 patients (31.1%) in the control group (p = 0.003). In patients undergoing thoracotomy for cancer resection, 3% in the EUS group, compared with 20% in the control group, were found to have malignant mediastinal lymph nodes at surgery (p = 0.01). There was also a trend toward lower yield of mediastinoscopy done for cancer diagnosis or staging in the EUS group (p = 0.08). Preoperative EUS in lung cancer patients may reduce unnecessary surgery at which advanced inoperable disease is discovered.

Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies

Diagnostic endoscopic retrograde cholangiography (ERC) is being replaced by endoscopic ultrasonography (EUS) in patients with suspected bile duct stones. The assumption that such an approach is advantageous, however, has never been tested in a randomized trial. 100 patients with intermediate probability of bile duct stones were randomly allocated to EUS or ERC. Two patients in the ERC group were excluded; the remaining 98 patients received the allocated intervention and were entered into the analysis (EUS, 50 patients; ERC, 48 patients). Detected stones were removed endoscopically; patients without stones were followed for 1 year. The primary end point was the proportion of patients with a negative outcome, related to either endoscopic procedures (complications) or to false-negative diagnosis of stones. Investigators assessing the negative outcomes were not blinded to group assignment. The secondary end point was the total number of endoscopic procedures (EUS and ERC) performed in each group to diagnose and treat stones. Bile duct stone prevalence was 28% and 25% in the EUS and ERC groups, respectively (P > 0.05). In the EUS group, 71 endoscopic procedures were performed, and 63 in the ERC group (mean per patient, 1.42 +/- 0.76, and 1.31 +/- 0.55, respectively; P > 0.05). In the EUS group, these included 49 successful and one failed initial EUS, 15 ERCs for bile duct stone treatment, and six procedures required during follow-up. In the ERC group there were 36 successful and 12 failed initial ERCs, 13 repeat procedures (EUS or ERC) performed after failed or equivocal initial ERC, and two procedures during follow-up. Five patients in the EUS group (10%, 95% CI 4-22) and 19 patients in the ERC group (40%, 95% CI 27-54) experienced a negative outcome (P < 0.001). No difference was observed when only moderate to severe complications were considered (6%, 95% CI 1-17, and 10%, 95% CI 4-23, respectively). In patients with intermediate probability of bile duct stones, the management strategy based on EUS (with selective ERC in patients with confirmed stones) is safer and not associated with an excess of endoscopic procedures compared with a strategy based on ERC alone.

Multi-Center Clinical Trial Using Endoscopy (END) and Endoscopic Ultrasound (EUS) Guided Fine Needle Injection (FNI) of Anti-Tumor Agent (TNFerade™) in Patients with Locally Advanced Esophageal Cancer

Introduction: Despite neoadjuvant therapy and aggressive surgical resections, the prognosis for esophageal cancer remains poor. TNFerade is a second-generation replication-deficient adenovector, carrying the transgene encoding for human TNF-α, regulated by the radiation-inducible promoter Egr-1. We previously reported EUS-guided FNI of TNFerade in pancreatic cancer. This is the first clinical trial using END/EUS to deliver an anti-tumor agent in patients with esophageal cancer. Methods: Multi-center dose-escalating study of TNFerade with concurrent neoadjuvant chemoradiation (45 Gy/25 fx/5 weeks, with 5-FU [1000 mg/m2/day × 96 hrs] plus cisplatin [75 mg/m2] on Days 1 and 29) in patients with resectable stage II and III esophageal cancer staged by CT and EUS. TNFerade was administered in 1-log inter-patient dose escalations from 4 × 108 - 4 × 1011 pu, via END (n = 18) or EUS (n = 6) once weekly × 5 weeks. Resection was performed 5-11 weeks after the end of radiation. Endpoints included maximum tolerated dose (MTD), safety and pathologic complete response rate (pCR). Results: 24 pts were enrolled. The majority of tumors were adenocarcinoma (20/24), T3 (23/24), and N1 (18/24). Ave # of injections/session = 3.9 ± 0.3. Ave time for injection was 4.5 ± 5.9 min. The MTD was not reached. The most frequent adverse events (AEs) judged potentially related to TNFerade were generally mild to moderate in severity and included fatigue (54%), fever (38%), and nausea (29%). Thromboembolic events occurred in 8/24 (33%) pts. In the top three dose cohorts, pCR was seen in 6/15 (40%) resected tumors, and 10/17 (59%) remain disease free at a range of follow-up from 13 to 25 months. At the 4 × 109 pu dose, pCR was seen in 3/3 (100%) resected tumors, with a radiographic complete response in a fourth patient; all four remain disease-free at 19 to 25 months. 20/24 pts went to surgery. The median survival has not been reached (19/24 pts still alive) with mean follow-up of 21 months. Comparison between END vs EUS showed no statistically significant differences in # injections (3.9 vs 3.9), pCR (22% vs 50%), alive status (78% vs 83%) or serious AE's (56% vs 50%); p = NS. Only time for injection was longer in EUS group (10 vs 3 min; p < .001). Conclusions: Endoscopy and EUS-guided FNI of TNFerade with concurrent chemoradiation is feasible and generally well-tolerated. TNFerade may result in increased pCR and optimize surgical and long-term outcomes. This represents a new treatment paradigm in esophageal cancer, with the endoscopist administering the local anti-tumor agent while assessing tumor response and local toxicity in real time.

Comparison of Early Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Management of Acute Biliary Pancreatitis: A Prospective Randomized Study

The role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients. A prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected. Examination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups. In selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

Endoscopic ultrasound: impact on survival in patients with esophageal cancer

Background Esophageal carcinoma is an aggressive malignancy and long-term survival is poor. Endoscopic ultrasound (EUS) is an additional staging modality to assess locoregional extent of this disease. We hypothesized that EUS may improve survival through more effective staging and better optimization of treatment. Methods We performed a retrospective review of all patients presenting with esophageal cancer at our institution from 1993 to 2003 ( n = 97) and compared outcomes between patients who underwent staging EUS and computed tomography (CT) versus CT alone. Survival was calculated using Kaplan-Meier methods and compared between groups using the log-rank test. Mean survival was compared using analysis of variance (ANOVA) methods. Results Overall 3-, 6-, and 12-month survival did not differ between the 2 groups (EUS: 92%, 84%, and 80% and CT: 83%, 67%, and 43%, log-rank P = .1), which held true despite stratification by treatment modality (all P >.1). The mean survival for the EUS group was 16 ± 3 months and for the CT group, 12 ± 1.5 months ( P = .2). Further analysis by stage showed no difference in survival between the 2 groups (all P >.1). However, stage 2A and 3 surgical patients had better survival than nonsurgical patients (both P = .02) irrespective of staging modality. EUS patients were no more likely to receive surgical, neoadjuvant, or definitive chemoradiation than CT patients (all P >.1). Conclusions Overall survival as well as survival by stage did not differ between patients who underwent staging via EUS and CT versus CT alone, and patients staged with EUS were not more likely to receive any one intervention. Irrespective of staging modality, stage 2A and 3 patients who underwent surgical intervention had better survival than those who did not receive an operation.

Assessment of clinical impact of endoscopic ultrasound on rectal cancer.

Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the most accurate imaging modality for locoregional staging of rectal cancer. It remains unclear whether this technology impacts the clinical outcome of patients with this malignancy. The aim of this study was to assess the impact of EUS FNA by comparing the clinical outcomes of patients with rectal cancer before and after the introduction of EUS in our institution. Outcomes of patients with de novo nonmetastatic rectal cancer seen in 1999 without EUS evaluation (non-EUS control group) were compared to patients evaluated in 2000/2001 with EUS FNA (EUS group). Outcomes of 68 (non-EUS control group) and 73 (EUS group) patients with nonmetastatic rectal cancer were compared. Among patients with advanced T or N stage, adjuvant therapy was administered to 45 patients (84.9%; preoperative to 31 (58.5%) patients and postoperative to 14 (26.4%)) in the EUS group; adjuvant therapy was administered to 37 patients (78.7%; preoperative to 7 (14.9%) patients and postoperative to 30 (63.8%)) in the non-EUS group. Cox proportional hazards demonstrated EUS FNA to be associated with reduced tumor recurrence risk, hazard ratio, 0.72 (95% CI: 0.52-0.97, p= 0.03). EUS staging of rectal cancer appears to facilitate appropriate employment of preoperative neoadjuvant therapy in those patients with advanced disease. EUS use is associated with a recurrence-free survival advantage in patients, supporting its routine use in rectal cancer staging.

Assessment of clinical impact of endoscopic ultrasound on esophageal cancer.

Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the most accurate imaging modality for locoregional staging of esophageal cancer. It remains unclear whether this technology impacts on the outcome of patients with this malignancy. The aim of the present study was to assess the impact of EUS FNA by comparing the clinical outcomes of patients with esophageal cancer before and after the introduction of this staging modality in our institution. Outcomes of patients with de novo non-metastatic esophageal cancer seen in 1998 without EUS FNA evaluation (non-EUS control group) were compared to patients evaluated in 2000 with EUS FNA (EUS group). Outcomes of 60 (non-EUS control group) and 107 (EUS group) patients with non-metastatic esophageal cancer were compared. Preoperative neoadjuvant therapy was administered to 35 patients in the EUS group, all of whom had advanced disease. Cox proportional hazards demonstrated EUS FNA to be associated with reduced recurrence risk (hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.43-0.87), P = 0.004, and reduced mortality (HR: 0.66; 95% CI: 0.47-0.90), P = 0.008. The EUS staging of esophageal cancer leads to appropriate use of preoperative neoadjuvant therapy in patients with advanced disease. Use of EUS is associated with a recurrence-free survival advantage and overall survival advantage in patients, thus supporting its routine use in esophageal cancer staging.

Cost effectiveness of EUS for preoperative localization of pancreatic endocrine tumors

Background: Endoscopic ultrasonography (EUS) is highly accurate in the localization of small pancreatic tumors. We determined the cost effectiveness of EUS used early in the preoperative evaluation of pancreatic endocrine tumors. Methods: In a study with a case-control design, 36 patients (19 men, 17 women) who underwent preoperative EUS were matched retrospectively with 36 patients who underwent surgical exploration immediately before the introduction of EUS. The number, cost, and effectiveness of preoperative localization studies, days of hospitalization, and surgical and anesthesia times were assessed. Results: The EUS group had reduced charges for preoperative localization studies: $2620 versus $4846 per patient ( p < 0.05), largely because of reductions in the number of diagnostic angiograms and venous sampling procedures performed. Surgical and total anesthesia times were decreased, as were the number of preoperative admissions for angiographic procedures. The cost-effectiveness ratio for the EUS group was $3144 per tumor localized compared with $5628 per tumor localized for the group treated before EUS became available ( p < 0.05). Conclusion: EUS is highly accurate in the localization of pancreatic neuroendocrine tumors and is cost effective when used early in the preoperative localization strategy. EUS decreased the need for additional invasive tests and avoided unnecessary morbidity and resource consumption. EUS should play a primary role in preoperative localization of pancreatic neuroendocrine tumors. (Gastrointest Endosc 1999;49:19-25.)