Diagnosis of pancreatic plasmacytoma by endoscopic ultrasound-fine needle aspiration.

Plasmacytoma presents more frequently in middle age men with aerodigestive tract involvement, especially in the head and the neck. Gastrointestinal tract involvement is uncommon, but the organ most commonly involved is the stomach. We report the first case in the literature in which final diagnosis was made by fine- needle aspiration biopsy guided by endoscopic ultrasound with adequate sample for pathologic analysis. The treatment of this entity is systemic chemotherapy but its effectiveness is limited. Plasmacytoma should be taken into account in differential diagnosis of pancreatic masses.

Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis.

BACKGROUND: Endoscopic ultrasonography (EUS) has emerged as an accurate diagnostic alternative to endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review of all randomized controlled trials of EUS-guided ERCP versus ERCP alone in patients with suspected choledocholithiasis. METHODS: The search for eligible studies was carried out using the MEDLINE, Cochrane Central Register of Controlled Trials, and Science Citation Index electronic databases. Meta-analysis was conducted using a random-effects model. RESULTS: Four trials containing 213 patients randomized to EUS-guided ERCP and 210 to ERCP alone were selected. In the EUS-guided ERCP group, ERCP was avoided in 143 patients (67.1 per cent) when EUS did not detect choledocholithiasis. The use of EUS significantly reduced the risk of overall complications (relative risk 0.35 (95 per cent confidence interval (c.i.) 0.20 to 0.62); P < 0.001) and post-ERCP acute pancreatitis (relative risk 0.21 (95 per cent c.i. 0.06 to 0.83); P = 0.030). CONCLUSION: By performing EUS first, ERCP may be safely avoided in two-thirds of patients with common bile duct stones. Application of EUS in the selection of patients for therapeutic ERCP significantly reduces the complication rate.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center.

BACKGROUND: Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy. METHODS: A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy. RESULTS: The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention. CONCLUSION: The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Interobserver agreement for EUS in the evaluation and diagnosis of submucosal masses.

INTRODUCTION: EUS is an accurate means of evaluating and diagnosing submucosal lesions of the GI tract. The aim of this study was to prospectively determine interobserver agreement for the EUS classification of submucosal masses among endosonographers with different levels of training and experience from multiple centers. METHODS: Twenty patients with submucosal mass lesions diagnosed by upper endoscopy underwent EUS. Surgical findings were available for 16 patients. In 4 patients with obvious cystic/vascular structures (i.e., varices) no surgical specimen was necessary. A blinded observer developed a study videotape of critical endoscopic and EUS real-time imaging for each lesion. The videotape was distributed to 10 endosonographers, each with at least 1 year of experience, who independently reviewed the videotape and recorded their diagnosis based on EUS features. These endosonographers used previously agreed-upon standardized EUS diagnostic criteria for each category of lesion. A kappa (kappa) statistic, used to evaluate agreement, was calculated for each lesion category for the 10 endosonographers as a group and individually. An overall kappa statistic was also calculated. Significance was analyzed with a two-tailed t test. RESULTS: Agreement was excellent for cystic lesions (kappa = 0.80) and extrinsic compressions (kappa = 0.94), good for lipoma (kappa = 0.65), fair for leiomyoma and vascular lesions (kappa = 0.53 and 0.54, respectively), and poor for other submucosal lesions (kappa = 0.34). Overall agreement among observers was good (kappa = 0.63). Furthermore, a significant association was noted between total years of EUS experience and the number of correct answers (p = 0.01). CONCLUSIONS: Interobserver agreement is good for characterizing submucosal masses by EUS. However, it appears to be better for some lesions than others. The overall length of experience with EUS appears to play an important role in the accuracy of this modality in the evaluation of submucosal lesions.

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.

Therapeutic endoscopy for nonvariceal gastrointestinal bleeding.

This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.

Radiographic changes after colonoscopic decompression for acute pseudo-obstruction.

PURPOSE: Colonoscopy has been the principal tool for decompression in acute colonic pseudo-obstruction, known as Ogilvie's syndrome. The objectives of this study were to determine the immediate effect of colonoscopy on the cecal diameter (measured on supine radiographs) and to delineate possible correlations in the diameters of dilated segments of the colon. METHODS: The charts and radiographs of 24 patients who had colonoscopic decompression for acute colonic pseudo-obstruction between 1992 and 1997 at the San Diego Veterans Affairs Medical Center and the University of California, San Diego Hospitals were reviewed. We measured cecal, transverse, descending, and sigmoid colon diameters on serial radiographs up to the point of clinical resolution. RESULTS: Mean +/- standard deviation cecal diameter change (between initial and post-decompression films) was -2+/-3.4 cm at four hours and -2.2+/-3.3 cm one day after decompression. On the daily radiographs between colonoscopic decompression and clinical resolution, there was a close correlation between the diameter of the cecum and that of the transverse colon (P<0.05). There was no correlation between the cecal diameter and that of the descending or sigmoid colon. CONCLUSIONS: Colonoscopic decompression only causes a small decrease in cecal size in the patient with acute colonic pseudo-obstruction. Dilation patterns of the cecum and transverse colon are significantly correlated in acute colonic pseudo-obstruction. This correlation provides additional support to the contention that the same pathophysiology affects these two segments of the colon.

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.

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach.

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.