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Can EUS replace diagnostic ERP?
ENDOSCOPIC ULTRASOUND ?557
?559
IS ENDOSCOPIC ULTRASONOGRAPHY (EUS) USEFUL FOR THE DIAGNOSIS OF RECTOSIGMOID ENDOMETRIOSIS ? G. Roseau. I. Dumontier, A. Berson, S. Chaussade, L. Palazzo, D. Couturier. Service d'Hepato-Gastroenteroh)gie, Hopiml Cochin, 75014 Paris, France.
BLIND THIN PROBE FOR ESOPHAGEAL ENDOSONOGRAPHY. JC Souauet. B Napoleon, O Keriven-Souquet, B Pujol, R Lambert. Department of Digestive Diseases, Hopital E Herriot, Lyon, France.
Fifteen percent of women with pelvic endometriosis had a rectal or sigmofdal localization. Barium enema and colonoscopy are rarely suggestive. EUS is a valuable and useful methcxl to study the rectal wall and surroundings. Aim of the study: to evaluate the ability of EUS in the diagnosis and the extension of rectosigmcil'dal localization in patient.~ with know pelvic endometriosis. Method: EUS was performed in 52 patients with inl'ertiiity or pelvic pains alone (n=48), or associatcd with hcmatochczia (n=8). Pelvic cndometriosis was confirmed in all cases on coclioscopy performcd within 45 days after EUS. Results: EUS was normal in 15 patients. In 37 eascs, cndometriosis was suspected on a 25 _+ 10 mm diameter hypocchoie mass bounded with the rectum (46%) or the rcctosigmoidal junction (54%). Rectal wall infiltration by cndomctriosis was considered when thickened musculans propria was seen in contact with pelvic cndometriosis (24/37). In other cases (13/37) EUS showed pelvic images at distance from digestive tract or pelvic images close to the rcctal wall but without thickened musculans propria. Endomctriosis involved only muscularis propna in 18/24 cases, submucosae in 4/24 and mucosac in 2/24. Eighty six percent (24/28) of patients with normal rectal wall on EUS had complete laparoscopic resection of pelvic endomctnosis (utcrosacral ligaments resection and coagulation of peritoneal implants), whcrcas complete resection was performcd only in 4/24 (17%) patmnts with rectal infilatration (p
Stenosis is a major limit in EUS exploration of esophageal and cardial cancer (30 to 40%). Systematic dilatation before EUS is presently not recommended as perforation has been reported with this association. Here was studied the potential interest of a blind thin probe that could be passed through esophageal stenosis on a guide wire. Methods: The blind thin probe prototype (Olympus Co) is characterized " by: working lenght 68.5 cm, diameter 7.9 mm, lack of optic bundle, operative channel, and succion channel, possibility to instillate water into the digestive lumen, unique 7.5 MHz transducer, small balloon around the probe, bending in the 4 directions. At the probe extremity, a coneshaped, perforated metallic tip allows the passage of a guide wire (0.038 inch). 45 examinations were performed in 44 patients (8 female, 36 male, mean age 59 yrs). 39 examinations were performed under anesthesia. 6 were performed without it and were better tolerated than standard EUS in similar conditions. 25 patients had a stenosis not or hardly passable with a video-endoscope. Indications were: staging of esophageal or cardial squamous cell (n=18) or glandular (n=6) cancer, evaluation of cancer anastomotic recurrence (n=4), follow-up of non surgical protocol in esophageal cancer (n=15), esophageal sub-mucosal tumor (n=l). Results: Examination was successfull in all cases. Guide wire was necessary only for 10 examinations. In the 35 other cases, the probe was passed blindly. No complication was noted. The quality of the examination (esophagus, posterior mediastinum) was similar to that given by echoendoscope GF UM20. Exploration was only limited by saliva stasis or air insufflated during gastroscopy (lack of succion) at the level of the esophagus (n=l), or the upper part of the stomach (n=5). 8 patients had thereafter surgery with tumor resection. The comparison with the operative specimen showed a good evaluation of the T status (accuracy 75%) with one over-estimation (squamous cell cancer treated by radiotherapy without residual tumor) and one under-estimation (staging of anastomotic recurrence). For N staging, accuracy was 87.5%. The 2 cases of mestastic nodes along the stomach under the cardia were well recognized. Conclusions: the blind thin probe was useful for the exploration of large tumors of the esophagus and cardia. It could be passed blindly or, in case of tight stenosis, on a guide wire. It gave the same accuracy than standard echoendoscopy for the staging of these cancers.
Conclusion: EUS could bc of intcrcst for thc diagnosis and the surgical management of patients with pelvic cndomctriosis, especially for the appraisal of the rcsccability.
?558
?56O
CAN EUS REPLACE DIAGNOSTIC ERP? U.Seitz, K.F.Binmoeller, H.Seifert, S.Bohnacker, U.Behrens, F: Thonke, N.Soehendra. Dept of Endoscopic Surgery, University Hospital, Hamburg, Germany Endoscopic ultrasonography (EUS), which allows assessment of ductal and parenchymal features of the pancreas, is an attractive alternative to endoscopic retrograde pancreatography (ERP) because of lower procedural risk. Aim: To determine whether ERP provides supplemental information to EUS in the subset of patients (pts) referred for diagnostic ERP. Methods: During an I t month period (1/95 11/95) 56 pts (median age 57, range 16-84) referred for diagnostic ERP underwent preliminary EUS on the same day. Indications were elevated pancreatic tumor markers (7), elevated pancreatic enzymes (17), unclear ultrasound and/or CT findings (14), clinical symptoms suggestive of pancreatic disease (34), and cholestasis suspected to be of pancreatic origin (14). EUS findings were entered into a database prior to ERP. In 27 pts EUS and ERP were performed by different examiners blinded to the results of the other. Results: EUS examination of the pancreatic head failed in 2 cases (postgastrectomy-1, failed pylorus intubation-1). Of the remaining 54 pts, ERP did not provide additional information to EUS in 50 (93%). In 1 pt ERP revealed a pancreatic duct fistula that was not seen on EUS. In 3 pts EUS showed changes of pancreatitis, but ERP showed complete ductal obstruction suggesting malignancy (follow-up pending). 25 pts with a normal EUS were found to have a normal ERP. In 9 pts EUS identified pathology (pancreatitis-7; malignancy, confirmed by histology-2) missed on ERP. EUS identified pathology in 2 cases where ERP had failed (duodenal stenosis-1, failed cannulation-1). Subgroup analysis of procedures performed by 2 blinded examiners (n=27) and by a single unblinded examiner (n=29) showed no differences. Conclusion: 1. EUS can replace ERP if a complete exam is normal. 2, An abnormal EUS may warrant ERP to detect additional pathology (eg., fistula, ductal obstruction). 3. EUS may need to be complemented by ERP in postgastrectomy patients to exclude pathology in the pancreatic head.
EXPLORATION OF THE DIGESTIVE WALL WITH A 20 MHZ RADIAL PROBE. Seuauet JC, Keriven-Souquet O, Napol6on B, Pujol B, Lambert R. Department of Digestive Diseases, HSpital E Herriot, Lyon, France.
430
GASTROINTESTINAL ENDOSCOPY
Small cancers of the digestive wall are well staged by endoscopic ultrasound (EUS). Indeed T1 cancer are well separated from more invasive tumor (accuracy 85%). However lymph node staging is poor in this setting. Risk of metastatic spread is much lower, especially in the esophagus, for mucosal cancer. The usual 7.5/12 MHz probe does not allow the distinction between mucosa and submucosa. We here studied a 20MHz probe, that could visualize 9 layers and allow this distinction. Methods: Olympus prototype, similar to GF UM20, had 2 frequencies 7.5/20MHz. It was used in 66 patients (32-85 yr) for staging of "small cancer" in the esophagus (n=23), the stomach (n=6), or the anus (n=2), evaluation of rectal villous adenoma (n=9), submucosal tumor (n=8) or follow-up of esophageal cancer treated by photodynamic therapy (n=18). The 30 first examinations were recorded and reviewed by the 4 operators in order to determine the number of layers visualized (9 or <9) in the normal digestive wall. In case of surgery, EUS results were compared with the operative specimen. Results: The digestive wall (5-7 layers) was always clearly visualized and perhaps better than with standard EUS. Surroundings were visualized on about 20 mm, making the pancreas examination difficult. In the duodenum, 9 layers were never seen. For the other parts of the GI tract, results are given in Table : N~ 9 doubtful 7
Rectum 40% 40% 20%
. . . . . . . . . . . . . . . . . . . . . . . . . .
Antrum 20% 20% 60%
Fundus 64% 18% 18%
Cardia 62% 25% 13%
EsoDhaaus 56% 13% 31%
=. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
At the level of the esophagus, doubtful results were mostly observed in case of previous radiotherapy. 13 patients were operated on for cancer (3pT3, 3pT2, 4pT1, 3pT0). EUS was accurate in all but one tumor (overstaging of pT0 tumor). It was able to determine the mucosai/submuc0sal extension of the 2 esophageal cancer operated on. For N staging (5pN1, 2pM1), EUS was always correct. Finally, the patient referred for submucosal tumor had an extrinsic lesion as shown by EUS. Conclusions: The 20MHz probe allowed a very good study of the digestive wall with visualization of 9 layers in about 60% of cases. While it had a limited depth of penetration, mediastinal and celiac nodes were well evaluated. It could allow the distinction of mucosal and submucosal cancer, but larger series are needed to confirm this hypothesis.
VOLUME 43, NO. 4, 1996
?559
IS ENDOSCOPIC ULTRASONOGRAPHY (EUS) USEFUL FOR THE DIAGNOSIS OF RECTOSIGMOID ENDOMETRIOSIS ? G. Roseau. I. Dumontier, A. Berson, S. Chaussade, L. Palazzo, D. Couturier. Service d'Hepato-Gastroenteroh)gie, Hopiml Cochin, 75014 Paris, France.
BLIND THIN PROBE FOR ESOPHAGEAL ENDOSONOGRAPHY. JC Souauet. B Napoleon, O Keriven-Souquet, B Pujol, R Lambert. Department of Digestive Diseases, Hopital E Herriot, Lyon, France.
Fifteen percent of women with pelvic endometriosis had a rectal or sigmofdal localization. Barium enema and colonoscopy are rarely suggestive. EUS is a valuable and useful methcxl to study the rectal wall and surroundings. Aim of the study: to evaluate the ability of EUS in the diagnosis and the extension of rectosigmcil'dal localization in patient.~ with know pelvic endometriosis. Method: EUS was performed in 52 patients with inl'ertiiity or pelvic pains alone (n=48), or associatcd with hcmatochczia (n=8). Pelvic cndometriosis was confirmed in all cases on coclioscopy performcd within 45 days after EUS. Results: EUS was normal in 15 patients. In 37 eascs, cndometriosis was suspected on a 25 _+ 10 mm diameter hypocchoie mass bounded with the rectum (46%) or the rcctosigmoidal junction (54%). Rectal wall infiltration by cndomctriosis was considered when thickened musculans propria was seen in contact with pelvic cndometriosis (24/37). In other cases (13/37) EUS showed pelvic images at distance from digestive tract or pelvic images close to the rcctal wall but without thickened musculans propria. Endomctriosis involved only muscularis propna in 18/24 cases, submucosae in 4/24 and mucosac in 2/24. Eighty six percent (24/28) of patients with normal rectal wall on EUS had complete laparoscopic resection of pelvic endomctnosis (utcrosacral ligaments resection and coagulation of peritoneal implants), whcrcas complete resection was performcd only in 4/24 (17%) patmnts with rectal infilatration (p
Stenosis is a major limit in EUS exploration of esophageal and cardial cancer (30 to 40%). Systematic dilatation before EUS is presently not recommended as perforation has been reported with this association. Here was studied the potential interest of a blind thin probe that could be passed through esophageal stenosis on a guide wire. Methods: The blind thin probe prototype (Olympus Co) is characterized " by: working lenght 68.5 cm, diameter 7.9 mm, lack of optic bundle, operative channel, and succion channel, possibility to instillate water into the digestive lumen, unique 7.5 MHz transducer, small balloon around the probe, bending in the 4 directions. At the probe extremity, a coneshaped, perforated metallic tip allows the passage of a guide wire (0.038 inch). 45 examinations were performed in 44 patients (8 female, 36 male, mean age 59 yrs). 39 examinations were performed under anesthesia. 6 were performed without it and were better tolerated than standard EUS in similar conditions. 25 patients had a stenosis not or hardly passable with a video-endoscope. Indications were: staging of esophageal or cardial squamous cell (n=18) or glandular (n=6) cancer, evaluation of cancer anastomotic recurrence (n=4), follow-up of non surgical protocol in esophageal cancer (n=15), esophageal sub-mucosal tumor (n=l). Results: Examination was successfull in all cases. Guide wire was necessary only for 10 examinations. In the 35 other cases, the probe was passed blindly. No complication was noted. The quality of the examination (esophagus, posterior mediastinum) was similar to that given by echoendoscope GF UM20. Exploration was only limited by saliva stasis or air insufflated during gastroscopy (lack of succion) at the level of the esophagus (n=l), or the upper part of the stomach (n=5). 8 patients had thereafter surgery with tumor resection. The comparison with the operative specimen showed a good evaluation of the T status (accuracy 75%) with one over-estimation (squamous cell cancer treated by radiotherapy without residual tumor) and one under-estimation (staging of anastomotic recurrence). For N staging, accuracy was 87.5%. The 2 cases of mestastic nodes along the stomach under the cardia were well recognized. Conclusions: the blind thin probe was useful for the exploration of large tumors of the esophagus and cardia. It could be passed blindly or, in case of tight stenosis, on a guide wire. It gave the same accuracy than standard echoendoscopy for the staging of these cancers.
Conclusion: EUS could bc of intcrcst for thc diagnosis and the surgical management of patients with pelvic cndomctriosis, especially for the appraisal of the rcsccability.
?558
?56O
CAN EUS REPLACE DIAGNOSTIC ERP? U.Seitz, K.F.Binmoeller, H.Seifert, S.Bohnacker, U.Behrens, F: Thonke, N.Soehendra. Dept of Endoscopic Surgery, University Hospital, Hamburg, Germany Endoscopic ultrasonography (EUS), which allows assessment of ductal and parenchymal features of the pancreas, is an attractive alternative to endoscopic retrograde pancreatography (ERP) because of lower procedural risk. Aim: To determine whether ERP provides supplemental information to EUS in the subset of patients (pts) referred for diagnostic ERP. Methods: During an I t month period (1/95 11/95) 56 pts (median age 57, range 16-84) referred for diagnostic ERP underwent preliminary EUS on the same day. Indications were elevated pancreatic tumor markers (7), elevated pancreatic enzymes (17), unclear ultrasound and/or CT findings (14), clinical symptoms suggestive of pancreatic disease (34), and cholestasis suspected to be of pancreatic origin (14). EUS findings were entered into a database prior to ERP. In 27 pts EUS and ERP were performed by different examiners blinded to the results of the other. Results: EUS examination of the pancreatic head failed in 2 cases (postgastrectomy-1, failed pylorus intubation-1). Of the remaining 54 pts, ERP did not provide additional information to EUS in 50 (93%). In 1 pt ERP revealed a pancreatic duct fistula that was not seen on EUS. In 3 pts EUS showed changes of pancreatitis, but ERP showed complete ductal obstruction suggesting malignancy (follow-up pending). 25 pts with a normal EUS were found to have a normal ERP. In 9 pts EUS identified pathology (pancreatitis-7; malignancy, confirmed by histology-2) missed on ERP. EUS identified pathology in 2 cases where ERP had failed (duodenal stenosis-1, failed cannulation-1). Subgroup analysis of procedures performed by 2 blinded examiners (n=27) and by a single unblinded examiner (n=29) showed no differences. Conclusion: 1. EUS can replace ERP if a complete exam is normal. 2, An abnormal EUS may warrant ERP to detect additional pathology (eg., fistula, ductal obstruction). 3. EUS may need to be complemented by ERP in postgastrectomy patients to exclude pathology in the pancreatic head.
EXPLORATION OF THE DIGESTIVE WALL WITH A 20 MHZ RADIAL PROBE. Seuauet JC, Keriven-Souquet O, Napol6on B, Pujol B, Lambert R. Department of Digestive Diseases, HSpital E Herriot, Lyon, France.
430
GASTROINTESTINAL ENDOSCOPY
Small cancers of the digestive wall are well staged by endoscopic ultrasound (EUS). Indeed T1 cancer are well separated from more invasive tumor (accuracy 85%). However lymph node staging is poor in this setting. Risk of metastatic spread is much lower, especially in the esophagus, for mucosal cancer. The usual 7.5/12 MHz probe does not allow the distinction between mucosa and submucosa. We here studied a 20MHz probe, that could visualize 9 layers and allow this distinction. Methods: Olympus prototype, similar to GF UM20, had 2 frequencies 7.5/20MHz. It was used in 66 patients (32-85 yr) for staging of "small cancer" in the esophagus (n=23), the stomach (n=6), or the anus (n=2), evaluation of rectal villous adenoma (n=9), submucosal tumor (n=8) or follow-up of esophageal cancer treated by photodynamic therapy (n=18). The 30 first examinations were recorded and reviewed by the 4 operators in order to determine the number of layers visualized (9 or <9) in the normal digestive wall. In case of surgery, EUS results were compared with the operative specimen. Results: The digestive wall (5-7 layers) was always clearly visualized and perhaps better than with standard EUS. Surroundings were visualized on about 20 mm, making the pancreas examination difficult. In the duodenum, 9 layers were never seen. For the other parts of the GI tract, results are given in Table : N~ 9 doubtful 7
Rectum 40% 40% 20%
. . . . . . . . . . . . . . . . . . . . . . . . . .
Antrum 20% 20% 60%
Fundus 64% 18% 18%
Cardia 62% 25% 13%
EsoDhaaus 56% 13% 31%
=. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
At the level of the esophagus, doubtful results were mostly observed in case of previous radiotherapy. 13 patients were operated on for cancer (3pT3, 3pT2, 4pT1, 3pT0). EUS was accurate in all but one tumor (overstaging of pT0 tumor). It was able to determine the mucosai/submuc0sal extension of the 2 esophageal cancer operated on. For N staging (5pN1, 2pM1), EUS was always correct. Finally, the patient referred for submucosal tumor had an extrinsic lesion as shown by EUS. Conclusions: The 20MHz probe allowed a very good study of the digestive wall with visualization of 9 layers in about 60% of cases. While it had a limited depth of penetration, mediastinal and celiac nodes were well evaluated. It could allow the distinction of mucosal and submucosal cancer, but larger series are needed to confirm this hypothesis.
VOLUME 43, NO. 4, 1996