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Endoscopic Ultrasound (EUS)-Guided FNA in Lung Cancer Staging-a Meta-Analysis of Diagnostic Performance
Abstracts
M1250 Direct Access Colonoscopy for General Practitioners in the Netherlands Is Feasible and Has a High Diagnostic Yield Bas Van Balkom, Peter J. Van Der Schaar
M1252 ERCP in Extreme Old Age Neil Galletly, Andrew N. Milestone, Gautam Mehta, Thomas C. Shepherd, Devinder S. Bansi, Andrew V. Thillainayagam
General practitioners (GP) have a central role in the Dutch health care system. Patients can only visit hospital specialists after referral by a GP. Although GP can usually order sigmoidoscopies and gastroscopies directly, colonoscopies can only be ordered by gastroenterologists after referral to the gastroenterology outpatient clinic. We assessed the feasibility of a direct access colonoscopy (DAC) program for GP. In addition, we retrospectively analysed the diagnostic yield of a DAC. Materials and Methods: With intervals of 2-6 months five groups of GP (totaling 130 GP) were formally trained about indications, contraindications and potential complications of colonoscopies. Thereafter they were allowed to request DAC. The first 1548 DAC were analyzed. Results: After 23 months all 130 GP were trained for the DACprogram. In 30 months 1548 DAC were performed. In this group, the mean age was 59 (range 16-91), 46.4% male. The median waiting time was 21 days (range 1-62) and did not significantly change after introduction of DAC. Indications included abdominal pain (30.1%), rectal bleeding (32.0%), altered bowel habits (31.6%) and various other indications (chronic diarrhea, follow up adenoma’s, hereditary cancer, anemia; all !10%). Endoscopic findings were colorectal carcinoma (4.5%), adenomatous polyps (18.9%), hyperplastic polyps (15.1%), inflammatory bowel disease (7.1%), hemorrhoids (11.4%), diverticular disease (25.7%) and miscellaneous (0.5%). No abnormalities were found in 31.5%. Colonoscopy was incomplete in 6.5%. The main indications abdominal pain, rectal bleeding and altered bowel habits did not predict presence of significant disease. Of all patients 80,7% was referred back to the GP, 19.3% required further specialist analysis and treatment: carcinoma and endoscopically irresectable polyps 5.6%, abdominal pain 3.2%, inflammatory bowel disease 2.9%, hereditary cancer syndromes 1.3%, complications of colonoscopy 0.6%, miscellaneous 5.7%. Conclusion: Implementation of DAC for a large group of GP is feasible within a relatively short amount of time. Significant disease is found in a high proportion of DAC. DAC may reduce gastroenterologist’s outpatient clinic workload and shift workload to endoscopies.
Introduction: As the population ages, pancreatobiliary disease is being seen with increasing frequency in the very elderly. Even though ERCP is effective in the diagnostic and therapeutic management of pancreatobiliary disease, there are significant complications associated with its use. A recent national audit in the UK of post-procedure complications found that 53% of peri-ERCP deaths were in patients over 80 years old. Given the paucity of data available on ERCP in the very elderly, concerns about its safety and suitability may limit its use in patients for whom the procedure may be appropriate. The aim of this study was to review our experience of ERCP in patients aged 90 and above. Methods: Retrospective review of the case records of all patients aged 90 years and above who had an ERCP between October 1997 and November 2005. Results: Thirty four patients (maximum age 105 y) underwent 46 ERCPs. The indications for the 34 initial ERCPs included obstructive jaundice (in 66% of all initial procedures), cholangitis (30%), and ultrasound/CT evidence of choledocholithiasis (55%) and/or biliary dilatation (55%). The indications for the 12 repeat ERCPs included follow-up and removal of biliary stones (58%) and stent replacement across a malignant stricture (25%). One procedure was performed under general anesthesia while the remainder received sedoanalgesia with midazolam (mean dose 4.8 mg) and an opiate (predominantly fentanyl - mean dose 83 mg). Reversal of sedation with flumazenil was given after 2 procedures. Deep bile duct cannulation and cholangiography was successful in 41 (89%) procedures; of the 5 failures, 2 subsequently had successful cholangiography on repeat ERCP. Periampullary diverticula were present in 36% of cases. All 31 patients in whom biliary access was achieved were found to have biliary pathology (choledocholithiasis in 83%, malignant biliary stricture in 17%). Complete bile duct clearance or pigtail stent insertion and biliary drainage was achieved in all cases of choledocholithiasis; all malignant biliary strictures were successfully stented. The only post-procedure complications observed were sphincterotomy-related bleeding (2 procedures) and pancreatitis (1 procedure); both bleeds were self-limiting and controlled endoscopically and the episode of pancreatitis was mild and resolved after 24 hours. There were no ERCP-related fatalities. Conclusion: ERCP in extreme old age can be performed safely with good success rates and high therapeutic efficacy.
M1251 A Closer Look At Same-Day Bidirectional Endoscopy. Jennifer Urquhart, MD, Douglas O. Faigel, MD, Nora Mattek, MPH, Jennifer Holub MA, MPH, David A. Lieberman, MD, Glenn Eisen, MD, MPH, Oregon Health & Science University, Portland, Oregon Jennifer L. Urquhart, Douglas O. Faigel, Nora Mattek, Jennifer Holub, David A. Lieberman, Glenn Eisen Background: Bidirectional same-day endoscopy is commonly performed in clinical practice. Current guidelines endorse the use of bidirectional endoscopy to evaluate GI bleeding and iron deficiency anemia when the first exam is not diagnostic. The aims of this study were to determine the: 1) frequency of same-day bidirectional endoscopy in diverse practice settings; 2) demographics and 3) prevalence of key endoscopic findings in specific cohorts with a common indication for both procedures. Methods: The CORI national endoscopic database was analyzed to determine the number of patients who had undergone same-day bidirectional endoscopy between 2000 and 2004. Patients with a single primary indication of anemia, positive fecal occult blood test (FOBT) or abdominal pain/dyspepsia (pain) on both EGD and colonoscopy were included for the analysis of endoscopic findings. Significant upper GI findings were defined as suspected malignancy, AVM, ulcer, Barretts esophagus and stricture. Findings of interest for the lower GI tract included suspected malignancy, polyp O 9 mm and AVM. Results: During the study period, 706,775 unique patients had upper and/or lower endoscopy. 66,265 patients (9.4%) had same-day bidirectional endoscopy. The mean age of patients undergoing bidirectional endoscopy was 60.8 years. The majority of patients were female (52.1%) and white/non-hispanic race (80.4%). 6,538 patients (9.9%) had anemia, 1169 (1.8%) had positive FOBT and 1360 (2.1%) had pain as the single indication for both exams. Patients with pain were younger (57.1 vs 64.7 years), and more likely to be female (61% female vs 49%) than patients with anemia or positive FOBT. The prevalence of significant findings on EGD and colonoscopy among the three groups are presented below. Fewer patients with pain had significant findings compared to the other two groups (p-value !0.0001). Conclusions: Almost 10% of unique patients undergoing upper and/or lower endoscopy receive same-day bidirectional endoscopy. Bidirectional endoscopy commonly revealed important pathology in patients with anemia or positive FOBT. Patients with pain had a lower rate of serious findings. Further studies are needed to determine the benefits of bidirectional endoscopy in patients with pain. Prevalence of Significant EGD and COL Findings for each group Anemia N (%) Significant EGD finding Significant COL finding
1061 (16.2%) 729 (11.2%)
Positive FOBT N (%) 158 (13.5%) 144 (12.3%)
Pain N (%) 110 (8.1%) 63 (4.6%)
AB152 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1253 Endoscopic Ultrasound (EUS)-Guided FNA in Lung Cancer Staging-a Meta-Analysis of Diagnostic Performance Carlos G. Micames, Darren A. Pavey, Paul S. Jowell, Douglas C. Mccrory, Frank G. Gress Background: Accurate staging of lung cancer is critical for deciding the most appropriate therapy. CT and PET are non-invasive tests limited by poor specificity. Invasive staging is commonly performed with mediastinoscopy. EUS-FNA is an alternative with less morbidity. Aim: To estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in lung cancer via meta-analysis of all studies in the literature. Methods: Relevant studies were identified using Medline (1966-November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow up (O6 mo) as gold-standard, and provided sufficient data for calculating sensitivity and specificity. Summary receiver-operating curves (SROC) meta-analysis with inverse-variance weighting and continuity correction for zero-cells was performed and used to estimate the pooled sensitivity and specificity. The effects of abnormal mediastinal lymph nodes (MLN) on CT and use of radial EUS prior to biopsy vs. linear EUS only on diagnostic performance were assessed. Two independent observers reviewed the studies for quality using items from the Standards for Reporting of Diagnostic Accuracy (STARD) statement. Results: 18 eligible, non-overlapping studies met inclusion criteria (1201 patients). 16 studies prospectively enrolled patients with suspected or proven lung cancer undergoing EUS-FNA for staging. 2 studies were retrospective database reviews. Among all studies, EUS-FNA had a pooled sensitivity 83% (95% CI: 79%-86%) and specificity 97% (97%-98%). Despite differences between studies in enrollment criteria and lymph node stations targeted during EUS-FNA, a statistical test for heterogeneity among all studies was not significant (p Z 0.77). In 560 cases (8 studies) with abnormal MLN on CT, the pooled sensitivity was 90% (88%-92%) and specificity was 97% (97%-98%). In patients without abnormal MLN on CT (175 cases; 4 studies), pooled sensitivity was much lower at 58% (25%-86%). False negative MLN were located in posterior stations (5, 7, 8, 9) in 58% and anterior stations (2, 3, 4, 6) in 42% of missed cases by EUS-FNA. Minor complications were reported in 10 cases (0.8%). There were no major complications. No differences in diagnostic performance were observed based on the use of combined radial and linear EUS vs. linear EUS alone. Conclusion: EUS-FNA is a safe modality for invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to MLN seen on CT. In addition, among lung cancer patients with normal MLN on CT, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT.
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M1250 Direct Access Colonoscopy for General Practitioners in the Netherlands Is Feasible and Has a High Diagnostic Yield Bas Van Balkom, Peter J. Van Der Schaar
M1252 ERCP in Extreme Old Age Neil Galletly, Andrew N. Milestone, Gautam Mehta, Thomas C. Shepherd, Devinder S. Bansi, Andrew V. Thillainayagam
General practitioners (GP) have a central role in the Dutch health care system. Patients can only visit hospital specialists after referral by a GP. Although GP can usually order sigmoidoscopies and gastroscopies directly, colonoscopies can only be ordered by gastroenterologists after referral to the gastroenterology outpatient clinic. We assessed the feasibility of a direct access colonoscopy (DAC) program for GP. In addition, we retrospectively analysed the diagnostic yield of a DAC. Materials and Methods: With intervals of 2-6 months five groups of GP (totaling 130 GP) were formally trained about indications, contraindications and potential complications of colonoscopies. Thereafter they were allowed to request DAC. The first 1548 DAC were analyzed. Results: After 23 months all 130 GP were trained for the DACprogram. In 30 months 1548 DAC were performed. In this group, the mean age was 59 (range 16-91), 46.4% male. The median waiting time was 21 days (range 1-62) and did not significantly change after introduction of DAC. Indications included abdominal pain (30.1%), rectal bleeding (32.0%), altered bowel habits (31.6%) and various other indications (chronic diarrhea, follow up adenoma’s, hereditary cancer, anemia; all !10%). Endoscopic findings were colorectal carcinoma (4.5%), adenomatous polyps (18.9%), hyperplastic polyps (15.1%), inflammatory bowel disease (7.1%), hemorrhoids (11.4%), diverticular disease (25.7%) and miscellaneous (0.5%). No abnormalities were found in 31.5%. Colonoscopy was incomplete in 6.5%. The main indications abdominal pain, rectal bleeding and altered bowel habits did not predict presence of significant disease. Of all patients 80,7% was referred back to the GP, 19.3% required further specialist analysis and treatment: carcinoma and endoscopically irresectable polyps 5.6%, abdominal pain 3.2%, inflammatory bowel disease 2.9%, hereditary cancer syndromes 1.3%, complications of colonoscopy 0.6%, miscellaneous 5.7%. Conclusion: Implementation of DAC for a large group of GP is feasible within a relatively short amount of time. Significant disease is found in a high proportion of DAC. DAC may reduce gastroenterologist’s outpatient clinic workload and shift workload to endoscopies.
Introduction: As the population ages, pancreatobiliary disease is being seen with increasing frequency in the very elderly. Even though ERCP is effective in the diagnostic and therapeutic management of pancreatobiliary disease, there are significant complications associated with its use. A recent national audit in the UK of post-procedure complications found that 53% of peri-ERCP deaths were in patients over 80 years old. Given the paucity of data available on ERCP in the very elderly, concerns about its safety and suitability may limit its use in patients for whom the procedure may be appropriate. The aim of this study was to review our experience of ERCP in patients aged 90 and above. Methods: Retrospective review of the case records of all patients aged 90 years and above who had an ERCP between October 1997 and November 2005. Results: Thirty four patients (maximum age 105 y) underwent 46 ERCPs. The indications for the 34 initial ERCPs included obstructive jaundice (in 66% of all initial procedures), cholangitis (30%), and ultrasound/CT evidence of choledocholithiasis (55%) and/or biliary dilatation (55%). The indications for the 12 repeat ERCPs included follow-up and removal of biliary stones (58%) and stent replacement across a malignant stricture (25%). One procedure was performed under general anesthesia while the remainder received sedoanalgesia with midazolam (mean dose 4.8 mg) and an opiate (predominantly fentanyl - mean dose 83 mg). Reversal of sedation with flumazenil was given after 2 procedures. Deep bile duct cannulation and cholangiography was successful in 41 (89%) procedures; of the 5 failures, 2 subsequently had successful cholangiography on repeat ERCP. Periampullary diverticula were present in 36% of cases. All 31 patients in whom biliary access was achieved were found to have biliary pathology (choledocholithiasis in 83%, malignant biliary stricture in 17%). Complete bile duct clearance or pigtail stent insertion and biliary drainage was achieved in all cases of choledocholithiasis; all malignant biliary strictures were successfully stented. The only post-procedure complications observed were sphincterotomy-related bleeding (2 procedures) and pancreatitis (1 procedure); both bleeds were self-limiting and controlled endoscopically and the episode of pancreatitis was mild and resolved after 24 hours. There were no ERCP-related fatalities. Conclusion: ERCP in extreme old age can be performed safely with good success rates and high therapeutic efficacy.
M1251 A Closer Look At Same-Day Bidirectional Endoscopy. Jennifer Urquhart, MD, Douglas O. Faigel, MD, Nora Mattek, MPH, Jennifer Holub MA, MPH, David A. Lieberman, MD, Glenn Eisen, MD, MPH, Oregon Health & Science University, Portland, Oregon Jennifer L. Urquhart, Douglas O. Faigel, Nora Mattek, Jennifer Holub, David A. Lieberman, Glenn Eisen Background: Bidirectional same-day endoscopy is commonly performed in clinical practice. Current guidelines endorse the use of bidirectional endoscopy to evaluate GI bleeding and iron deficiency anemia when the first exam is not diagnostic. The aims of this study were to determine the: 1) frequency of same-day bidirectional endoscopy in diverse practice settings; 2) demographics and 3) prevalence of key endoscopic findings in specific cohorts with a common indication for both procedures. Methods: The CORI national endoscopic database was analyzed to determine the number of patients who had undergone same-day bidirectional endoscopy between 2000 and 2004. Patients with a single primary indication of anemia, positive fecal occult blood test (FOBT) or abdominal pain/dyspepsia (pain) on both EGD and colonoscopy were included for the analysis of endoscopic findings. Significant upper GI findings were defined as suspected malignancy, AVM, ulcer, Barretts esophagus and stricture. Findings of interest for the lower GI tract included suspected malignancy, polyp O 9 mm and AVM. Results: During the study period, 706,775 unique patients had upper and/or lower endoscopy. 66,265 patients (9.4%) had same-day bidirectional endoscopy. The mean age of patients undergoing bidirectional endoscopy was 60.8 years. The majority of patients were female (52.1%) and white/non-hispanic race (80.4%). 6,538 patients (9.9%) had anemia, 1169 (1.8%) had positive FOBT and 1360 (2.1%) had pain as the single indication for both exams. Patients with pain were younger (57.1 vs 64.7 years), and more likely to be female (61% female vs 49%) than patients with anemia or positive FOBT. The prevalence of significant findings on EGD and colonoscopy among the three groups are presented below. Fewer patients with pain had significant findings compared to the other two groups (p-value !0.0001). Conclusions: Almost 10% of unique patients undergoing upper and/or lower endoscopy receive same-day bidirectional endoscopy. Bidirectional endoscopy commonly revealed important pathology in patients with anemia or positive FOBT. Patients with pain had a lower rate of serious findings. Further studies are needed to determine the benefits of bidirectional endoscopy in patients with pain. Prevalence of Significant EGD and COL Findings for each group Anemia N (%) Significant EGD finding Significant COL finding
1061 (16.2%) 729 (11.2%)
Positive FOBT N (%) 158 (13.5%) 144 (12.3%)
Pain N (%) 110 (8.1%) 63 (4.6%)
AB152 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1253 Endoscopic Ultrasound (EUS)-Guided FNA in Lung Cancer Staging-a Meta-Analysis of Diagnostic Performance Carlos G. Micames, Darren A. Pavey, Paul S. Jowell, Douglas C. Mccrory, Frank G. Gress Background: Accurate staging of lung cancer is critical for deciding the most appropriate therapy. CT and PET are non-invasive tests limited by poor specificity. Invasive staging is commonly performed with mediastinoscopy. EUS-FNA is an alternative with less morbidity. Aim: To estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in lung cancer via meta-analysis of all studies in the literature. Methods: Relevant studies were identified using Medline (1966-November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow up (O6 mo) as gold-standard, and provided sufficient data for calculating sensitivity and specificity. Summary receiver-operating curves (SROC) meta-analysis with inverse-variance weighting and continuity correction for zero-cells was performed and used to estimate the pooled sensitivity and specificity. The effects of abnormal mediastinal lymph nodes (MLN) on CT and use of radial EUS prior to biopsy vs. linear EUS only on diagnostic performance were assessed. Two independent observers reviewed the studies for quality using items from the Standards for Reporting of Diagnostic Accuracy (STARD) statement. Results: 18 eligible, non-overlapping studies met inclusion criteria (1201 patients). 16 studies prospectively enrolled patients with suspected or proven lung cancer undergoing EUS-FNA for staging. 2 studies were retrospective database reviews. Among all studies, EUS-FNA had a pooled sensitivity 83% (95% CI: 79%-86%) and specificity 97% (97%-98%). Despite differences between studies in enrollment criteria and lymph node stations targeted during EUS-FNA, a statistical test for heterogeneity among all studies was not significant (p Z 0.77). In 560 cases (8 studies) with abnormal MLN on CT, the pooled sensitivity was 90% (88%-92%) and specificity was 97% (97%-98%). In patients without abnormal MLN on CT (175 cases; 4 studies), pooled sensitivity was much lower at 58% (25%-86%). False negative MLN were located in posterior stations (5, 7, 8, 9) in 58% and anterior stations (2, 3, 4, 6) in 42% of missed cases by EUS-FNA. Minor complications were reported in 10 cases (0.8%). There were no major complications. No differences in diagnostic performance were observed based on the use of combined radial and linear EUS vs. linear EUS alone. Conclusion: EUS-FNA is a safe modality for invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to MLN seen on CT. In addition, among lung cancer patients with normal MLN on CT, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT.
www.giejournal.org