Comparison of propofol deep sedation versus moderate sedation during endosonography.

BACKGROUND: The purposes of this study are: (1) to prospectively evaluate clinically relevant outcomes including sedation-related complications for endoscopic ultrasound (EUS) procedures performed with the use of propofol deep sedation administered by monitored anesthesia care (MAC), and (2) to compare these results with a historical case-control cohort of EUS procedures performed using moderate sedation provided by the gastrointestinal (GI) endoscopist. MATERIALS AND METHODS: Patients referred for EUS between January 1, 2001 and December 31, 2002 were enrolled. Complication rates for EUS using MAC sedation were observed and also compared with a historical case-control cohort of EUS patients who received meperidine/midazolam for moderate sedation, administered by the GI endoscopist. Logistic regression analysis was used to isolate possible predictors of complications. RESULTS: A total of 1,000 patients underwent EUS with propofol sedation during the period from January 1, 2001 through December 31, 2002 (mean age 64 years, 53% female). The distribution of EUS indications based on the primary area of interest was: 170 gastroduodenal, 92 anorectal, 508 pancreaticohepatobiliary, 183 esophageal, and 47 mediastinal. The primary endpoint of the study was development of sedation-related complications occurring during a performed procedure. A total of six patients experienced complications: duodenal perforation (one), hypotension (one), aspiration pneumonia (one), and apnea requiring endotracheal intubation (three). The complication rate with propofol was 0.60%, compared with 1% for the historical case-control (meperidine/midazolam moderate sedation) group. CONCLUSIONS: There does not appear to be a significant difference between complication rates for propofol deep sedation with MAC and meperidine/midazolam administered for moderate sedation.

Retrospective analysis of the utility of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic masses, using a 22-gauge or 25-gauge needle system: a multicenter experience.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is now performed routinely in many advanced endoscopy centers and has enhanced the ability to diagnose pancreatic masses. However, there is uncertainty about which needle size is optimal for EUS-FNA of pancreatic masses. We aimed to evaluate the performance of the 22-gauge and 25-gauge needles in obtaining cytologic diagnosis of pancreatic masses. METHODS: All cases that were referred for EUS-FNA for pancreatic masses between February 2001 and June 2007 were reviewed, and patients who underwent EUS-FNA using the 22-gauge and 25-gauge needle system were identified. In patients who underwent surgery, operative histopathological findings were compared with the cytopathological findings from EUS-FNA. RESULTS: A total of 842 patients with pancreatic masses detected on computed tomography (CT) and/or magnetic resonance imaging (MRI) and confirmed by EUS underwent EUS-FNA with the 22-gauge needle (n = 540) or the 25-gauge needle (n = 302). Results of EUS-FNA cytology findings were compared with the gold standard of surgical histopathological findings or long-term clinical follow-up. The sensitivity, specificity, PPV, and NPV of FNA were respectively 84%, 100%, 100%, and 73% [corrected] for the 22-gauge needle compared with 92%, 97%, 98%, and 87%, [corrected] respectively for the 25-gauge needle. No complications were noted in the 25-gauge needle group, compared with pancreatitis in 2% of the 22-gauge needle group. CONCLUSIONS: This retrospective comparative study shows that EUS-FNA with a 25-gauge needle system is a safe and reliable method for tissue sampling in pancreatic masses. The system is more sensitive and has a slightly [corrected] higher NPV than the standard 22-gauge needle. Our study suggests that perhaps the smaller caliber FNA needle causes less trauma during EUS-FNA and hence less complications. Further studies including randomized trials are needed.

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

BACKGROUND AND STUDY AIMS: The purpose of this study was to identify possible associated factors that may have contributed to failure to detect a pancreatic neoplasm during endoscopic ultrasound (EUS) examinations by experienced endosonographers. PATIENTS AND METHODS: A multicenter retrospective study was organized, and 20 cases of pancreatic neoplasms missed by nine experienced endosonographers were identified. Careful analysis of each case was carried out to identify the factors that might have led to the missed diagnosis on EUS. RESULTS: Twelve patients with a missed pancreatic neoplasm had EUS features of chronic pancreatitis. Other factors that might have increased the likelihood of a false-negative EUS examination included a diffusely infiltrating carcinoma (n = 3), a prominent ventral/dorsal split (n = 2), and a recent episode (within the previous 4 weeks) of acute pancreatitis (n = 1). Five patients with a negative initial EUS underwent a follow-up EUS after 2-3 months, with a pancreatic mass being found in all cases. Three patients had a diffusely infiltrating pancreatic adenocarcinoma. CONCLUSIONS: EUS is not a foolproof method of detecting a pancreatic neoplasm. Possible associated factors that may increase the likelihood of a false-negative EUS examination include chronic pancreatitis, a diffusely infiltrating carcinoma, a prominent ventral/dorsal split and a recent episode (< 4 weeks) of acute pancreatitis. If there is a high clinical suspicion of pancreatic neoplasm, if EUS and other imaging methods are negative, and if the patient does not undergo surgery, this study suggests that a repeat EUS after 2-3 months may be useful for detecting an occult pancreatic neoplasm.

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

BACKGROUND: Endoscopic ultrasound (EUS) is a minimally invasive, low risk method of diagnosis for chronic pancreatitis (CP). The degree to which endosonographers agree on the features and diagnosis of CP is unknown. For EUS to be considered an accurate test for CP, there must be good interobserver agreement. METHODS: Forty-five pancreatic EUS examinations were videotaped by 3 experienced endosonographers. Examinations from 33 patients with suspected CP based on typical symptoms, as well as 12 control patients without suspected CP, were included. Eleven experienced endosonographers ("experts") who were blinded to clinical information independently evaluated all videotaped examinations for the presence of CP and the following 9 validated features of CP: echogenic foci, strands, lobularity, cysts, stones, duct dilatation, duct irregularity, hyperechoic duct margins, and visible side branches. The experts also ranked (most to least) which features they believed to be the most indicative of CP. Interobserver agreement was expressed as the kappa (kappa) statistic. RESULTS: There was moderately good overall agreement for the final diagnosis of CP (kappa = 0.45). Agreement was good for individual features of duct dilatation (kappa = 0.6) and lobularity (kappa = 0.51) but poor for the other 7 features (kappa < 0.4). The expert panel had consensus or near consensus agreement (greater than 90%) on 206 of 450 (46%) individual EUS features including 22 of 45 diagnoses of CP. Agreement on the final diagnosis of CP was moderately good for those trained in third tier fellowships (kappa = 0.42 +/- 0.03) and those with more than 1100 lifetime pancreatic EUS examinations (kappa = 0.46 +/- 0.05). The presence of stones was regarded as the most predictive feature of CP by all endosonographers, followed by visible side branches, cysts, lobularity, irregular main pancreatic duct, hyperechoic foci, hyperechoic strands, main pancreatic duct dilatation, and main duct hyperechoic margins. The most common diagnostic criterion for the diagnosis of CP was the total number of features (median 4 or greater, range 3 or greater to 5 or greater). CONCLUSIONS: EUS is a reliable method for the diagnosis of chronic pancreatitis with good interobserver agreement among experienced endosonographers. Agreement on the EUS diagnosis of chronic pancreatitis is comparable to other commonly used endoscopic procedures such as bleeding ulcer stigmata and computed tomography of the brain for stroke localization and better than the physical diagnosis of heart sounds.

1999 ASGE endoscopic ultrasound survey. ASGE Ad Hoc Endoscopic Ultrasound Committee.

BACKGROUND: Gastrointestinal endoscopic ultrasound (EUS) has become an important imaging modality for the diagnosis and staging of gastrointestinal disorders. This study assessed current EUS practice, training, coding, and reimbursement in the United States. METHODS: A direct mail survey was sent to members of the American Society for Gastrointestinal Endoscopy. RESULTS: There were 115 American respondents. The median age was 39 years, 57% were in academic practice, and 84% performed endoscopic retrograde cholangiopancreatography. The median number of EUS procedures performed was 200. In the preceding year, the median number of upper EUS was 60, lower EUS 10, and EUS/fine-needle aspiration 3. The most common indication was evaluation of esophageal or gastric lesions. Forty-six (40%) trained an average of 0.4 advanced fellows in EUS during the prior year. Of endosonographers involved in training, 53% thought formal training was necessary, for a median of 6 months and 100 procedures; 82% did not know whether they were reimbursed for EUS. There was great variation in the use of current procedural terminology (CPT) codes for lower EUS and upper EUS/fine-needle aspiration. CONCLUSIONS: EUS in the United States in 1999 is performed mostly by young, academic, interventional endoscopists. Diagnostic upper EUS is most commonly performed. Few new endosonographers are being trained. There is great variability in CPT coding of lower EUS and EUS/fine-needle aspiration procedures.

Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience.

BACKGROUND: Current methods for staging pancreatic cancer can be inaccurate, invasive, and expensive. Endoscopic ultrasound (EUS) is reported to be highly accurate for local staging of gastrointestinal tumors including pancreatic cancer. The aim of this study was to assess the utility of EUS and CT for staging pancreatic cancer by comparing staging accuracies in surgical patients and evaluating the potential impact of EUS staging and training. METHODS: This was a preoperative comparison of the diagnostic operating characteristics of these procedures in a referral-based academic medical center. Data were collected on 151 consecutive patients referred with confirmed pancreatic cancer between April 1990 and November 1996. All patients had preoperative CT and EUS performed for staging. In patients undergoing surgery, the surgical staging and/or findings were used to confirm EUS and CT staging. RESULTS: Eighty-one (60%) of 151 patients underwent surgery and made up the study subset. In these 81 patients, surgical exploration provided a final T staging in 93% (75 of 81), N staging in 88% (71 of 81) and data on vascular invasion in 93% (75 of 81). In the surgical patient group, with surgical correlation, EUS accuracy for T staging was as follows: T1 92%, T2 85%, T3 93%, and for N staging was: N0 72%, and N1 72%. CT accuracy for T staging was as follows: T1 65%, T2 67%, T3 38%, and for N staging was as follows: N0 52% and N1 100%. CT failed to detect a mass in 26% of patients with a confirmed tumor at surgery. Overall accuracy for T and N staging was 85% and 72% for EUS and 30% and 55% for CT, respectively. The ability to accurately predict vascular invasion was 93% for EUS and 62% for CT (p < 0.001). EUS was 93% accurate for predicting local resectability versus 60% for CT (p < 0.001). Last, the data were divided into two groups for the senior endosonographer's experience: procedures performed between 1990 and 1992 (98 cases) and 1993 and 1994 (53 cases). This analysis revealed that 7 of 9 instances of mis-staging (78%) occurred in the earlier group, during the learning phase for EUS. CONCLUSIONS: EUS is more accurate than CT for staging pancreatic malignancies, including predicting vascular invasion and local resectability. EUS staging was significantly better than CT for T1, T2, and T3 tumors. EUS staging accuracy improved after 100 cases, thus suggesting a correlation between the accuracy of EUS staging and the number of procedures performed.

Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.

BACKGROUND: Current methods for detecting mediastinal lymph node involvement with non-small-cell lung cancer can be inaccurate and are often invasive and expensive. OBJECTIVE: To assess the utility of endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography for the detection of metastases to the posterior mediastinal lymph nodes in non-small-cell lung cancer. DESIGN: Prospective preoperative evaluation of the diagnostic operating characteristics of these procedures. SETTING: Referral-based academic medical center. PATIENTS: 130 consecutive patients with non-small-cell lung cancer who were otherwise good surgical candidates. INTERVENTIONS: All patients had initial computed tomography of the chest; those with enlarged nodes were referred for endoscopic ultrasonography. Endoscopic ultrasonography-guided fine-needle aspiration biopsy was done on suspicious contralateral posterior mediastinal or subcarinal lymph nodes identified by ultrasonography. At surgery, lymph nodes were dissected and categorized by location and underwent histopathologic evaluation. RESULTS: 52 patients were ultimately enrolled in the study: Thirty-one had thoracotomy with mediastinal dissection, and 21 had tumors considered unresectable on the basis of preoperative evaluation. Ultrasonography without aspiration biopsy had an overall accuracy of 84% for predicting metastasis to lymph nodes; computed tomography had an accuracy of 49% (P < 0.025). Twenty-four patients had ultrasonography-guided aspiration biopsy; 14 of 24 were ineligible for surgery because cytology showed malignancy. Results of surgical pathology correlated with negative aspiration cytology results in 9 of 10 patients, the one node with false-negative results contained a 2-mm focus of cancer. The accuracy of ultrasonography-guided aspiration biopsy in diagnosing metastasis to lymph nodes was 96%; the results of this test prompted a change in management in 95% of the patients who had the procedure. CONCLUSIONS: Endoscopic ultrasonography alone or with fine-needle aspiration biopsy adds useful diagnostic information in determining metastasis to posterior mediastinal or subcarinal lymph nodes in patients with non-small-cell lung-cancer. These procedures are especially helpful in the preoperative evaluation of patients with suspicious contralateral mediastinal or "bulky" subcarinal nodes.

Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography.

BACKGROUND: Endoscopic ultrasound (EUS) accurately stages gastrointestinal malignancies but is less able to differentiate between neoplastic and inflammatory processes. EUS-guided fine-needle aspiration (EUS FNA) has been reported useful for obtaining a diagnosis in suspected gastrointestinal lesions. We report our entire experience with EUS FNA using both radial and linear array endosonography, including our diagnostic accuracy and complication rate. METHODS: Two hundred eight consecutive patients (119 men, 89 women) referred for EUS evaluation of suspected gastrointestinal or mediastinal masses underwent EUS-guided FNA. We performed EUS FNA using radial scanning or linear array endosonography and a 23 gauge, 4 cm needle or a 22 gauge, 12 cm needle. Data collected included lesion types, number of passes, complications, and diagnostic accuracy. RESULTS: Two hundred eight lesions were targeted, with a total of 705 FNA passes (mean 3.39 passes/patient). Overall diagnostic accuracy for our study population was 87% with a 89% sensitivity and 100% specificity. The diagnostic accuracy for each subgroup was 95% for mediastinal lymph node, 85% for intra-abdominal lymph node, 85% for pancreatic, 84% for submucosal, and 100% for perirectal masses. EUS FNA provided an adequate specimen in 90% of patients. The FNA results were similar for both types of endosonography. We observed immediate complications in 2% (4 of 208) of patients. All complications occurred with EUS FNA of pancreatic lesions and consisted of bleeding and pancreatitis in 2 patients each. For EUS FNA of pancreatic masses there was a 1.2% (2 of 121) risk of pancreatitis, 1% (1/121) risk of severe bleeding, and risk of death in less than 1%. CONCLUSIONS: EUS-guided FNA appears to be technically feasible, safe, and accurate for obtaining diagnostic tissue of suspicious gastrointestinal and mediastinal lesions and provides important preoperative information.

5-year incidence of adenomas after negative colonoscopy in asymptomatic average-risk persons [see comment].

BACKGROUND & AIMS: Cost-effectiveness of colorectal cancer screening will be maximized by selecting the widest screening intervals that effectively prevent cancer mortality. However, data on the incidence of neoplasia in persons with no abnormal findings on initial examination are limited. The aim of this study was to describe the incidence of colonic neoplasia 5 years after negative screening colonoscopy in asymptomatic average-risk persons. METHODS: We previously reported the results of screening colonoscopy in 496 asymptomatic average-risk persons, 368 of whom had no neoplasia identified. Colonoscopy to the cecum was performed in 154 of these persons at a mean of 66 months after the initial negative colonoscopy. RESULTS: Forty-one (27%) had at least one adenoma, but only 1 person had an adenoma > or = 1 cm and none had cancer, severe dysplasia, or villous or tubulovillous histology. Hyperplastic polyps at the initial examination did not predict incident adenomas. Regular nonsteroidal anti-inflammatory drug use was associated with a decreased rate of incident adenomas. CONCLUSIONS: In average-risk persons, the interval between screening examinations can be safely expanded beyond 5 years, provided the initial examination is a carefully performed complete colonoscopy that is negative for colonic adenomas or cancer.

Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP.

BACKGROUND: Polyethylene pancreatic duct stents induce morphologic changes of the pancreatic duct in the majority of patients. This study was undertaken to determine if parenchymal abnormalities are present in patients undergoing short-term pancreatic duct stenting and to correlate these findings with the pancreatogram obtained at stent removal. METHODS: Twenty-five patients underwent pancreatic duct stenting and had an endoscopic ultrasound evaluation of the pancreas at stent removal. The pancreatograms were evaluated at stent removal for ductal irregularity, narrowing, and side branch changes. Endoscopic ultrasound was used to assess for differences in the echo characteristics of the pancreatic parenchyma around the stent compared with the rest of the gland. RESULTS: Of the 16 patients evaluated by ERCP at stent removal, 9 (56%) had 1 or more new ductographic changes. Endoscopic ultrasound identified parenchymal changes in the stented region in 17 of 25 patients (68%). Four patients who had parenchymal changes in the stented region on endoscopic ultrasound at stent removal had a follow-up study at a mean time of 16 months. Two patients had (new) changes suggestive of focal chronic pancreatitis in the stented region. CONCLUSION: Short-term pancreatic duct stenting induced both ductal and parenchymal changes in more than 50% of patients. Chronic pancreatitis may be a consequence of pancreatic duct stenting.

Detection of embryologic ventral pancreatic parenchyma with endoscopic ultrasound.

BACKGROUND: The prevalence of detecting the embryologic ventral pancreas (ventral anlage) with endoscopic ultrasound (EUS) is unknown. PURPOSE: To determine the frequency of, and factors associated with, EUS findings consistent with the ventral anlage. METHODS: One hundred patients undergoing upper gastrointestinal EUS for any indication were prospectively evaluated for the presence of a focal, hypoechoic area in the pancreatic head using a radial scanning echoendoscope. Multiple clinical and EUS variables were tested against the ability to detect the ventral anlage. RESULTS: The overall detection rate of the ventral anlage was 59%. The ventral anlage was detected in 75% of patients undergoing EUS for nonpancreatic indications, compared to 40% of patients undergoing EUS to evaluate suspected pancreatic disease (p< 0.001). EUS detected the ventral anlage in 72% of patients with a normal EUS-appearing pancreatic head, compared to 29% of patients who had abnormal pancreatic head parenchyma (mass or chronic pancreatitis) on EUS (p < 0.001). Multivariate analysis revealed the only variable associated with detecting the ventral anlage was abnormal pancreatic head parenchyma on EUS. CONCLUSION: The ventral anlage is frequently detected during pancreatic EUS, with a significantly lower rate of detection in patients with EUS findings of a pancreatic head mass or diffuse chronic pancreatitis.

Dysphagia due to mediastinal granulomas: diagnosis with endoscopic ultrasonography.

BACKGROUND & AIMS: Mediastinal granulomas due to histoplasmosis can cause dysphagia and can be difficult to diagnose. The aim of this study was to describe the endoscopic ultrasonography (EUS) findings of suspected mediastinal granulomas. METHODS: Eleven patients with dysphagia were referred for EUS because endoscopy showed a midesophageal submucosal mass or stricture. RESULTS: All patients had similar EUS findings of a large mass of matted, posterior mediastinal lymph nodes that were adherent to a focally thickened esophageal wall. The cause of the mediastinal granulomas was believed to be histoplasmosis because 3 of the patients had positive complement fixation titers of 1:32, 1 of whom had a surgical resection showing a caseating granuloma. The diagnosis of histoplasmosis mediastinal granulomas was also supported by the findings of lymph node calcification on EUS in 7 patients, the presence or development of midesophageal traction diverticula in 5 patients, and clinical improvement after oral antifungal drug therapy in 7 patients. No patient developed evidence of malignancy during a mean follow-up period of 20.5 months. CONCLUSIONS: Based on characteristic EUS findings, mediastinal granulomas are believed to occur in patients with dysphagia who have a midesophageal submucosal mass or stricture on endoscopy and who live in a highly endemic area for histoplasmosis.