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Evaluation of submucosal lesions: Does EUS direct management
ENDOSCOPIC ULTRASOUND ~553
~555
THE USE OF ENDOSCOPIC ULTRASONOGRAPHY TO REDUCE THE COST OF TREATING AMPULLARY TUMORS. D. Quirk, D. Rat~ner, C. Fernandez, A. Warshaw, and W. Bmgge, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA
ENDOSOPIC ULTRASONOGRAPHYIN CLINICAL PRACTICE: PERFORMANCE, COMPLICATIONS A N D PATIENT ACCEPTANCE I . RSsch. H.D. Aileseher, R. Lorenz, G. Wiilkomm, M. Classen, Department of Internal Medicine I1, Technical University of Munich, Germany
Introduction: Endoscopic ultrasonography (EUS) has been used to stage ampullary tumors The treatment for benign and malignant tumors is resection, either local excision or Whipple resection. Local excision of ampullary tumors may result in the same benefit with less morbidity, mortality, and cost. Traditional preoperative staging with CT and angiography have been unsuccessful at differentiating local from invasive tumors The purpose of this study was to deternune if EUS could aid in the selection of patients for local resection and if there was a sigmficant cost difference between the two surgical procedures. Methods: A retrospective study was conducted on 29 patients who underwent surgery for ampullary tumors between April of 1993 and August of 1995. EUS (radial-5; linear-10) was performed on 15 patients and T staging was determined by blinded interpretation Resected specimens were used to determine pathologic T staging Local disease was defined as stage T2 or less. Cost data was available on 14 patients An external cost accounting firm was used to provide the total cost of hospitalization for surgical resection. The hospitalization costs of patients in the local resection group and the Whipple group were compared. Results: Ten of the 15 patients who underwent EUS had a pathologically confirmed localized ampnilary tumor Eight of the 10 patients with localized disease were correctly staged by EUS for a sensitivity of 80%. All 8 patients staged by EUS as having local disease were confirmed with pathologic staging (positive predictive value was 100%). The median total cost for a local resection was $9,589 vs $19,752 for a Whipple resection (p < 0 003). Conclusion: EUS is an effective tool for identifying patients with localized ampullary tumors The cost of a local resection for ampullary tumors is significantlyless than that of a Whipple reseciaon.. The use of EUS to select patients for local resection is a cost effective technique in the management of patients with ampullary tumors.
Background: Endoscopic uitrasonography (EUS) has been used for a variety of indications, but little data is available about the actual performance of the examination (sedation, examination time) and about patient acceptance. Patients and Methods: In a prospective study, 397 consecutive patients (age 22-78 years) were included. Indications were classified by the three examiners according to interaafioual consensus papers into I (established), 2 (useful), 3 (potentially useful), 4 (questionable) and 5 (wrong). Premedicatlon, complications and patient acceptance (using a questionnaire) were also recorded. All out-patients were monitored in a dayclinic for a few hours after EUS. 310 ,patients agreed to answer a questionnaire after EUS when they were fully conscious. Results: The classification of indications was 1 in 34%, 2 in 10%, 3 in 39%, 4 in 1 1 % and 5 in 6% of cases. Examination time was a mean of 9 rain. for esophagogastric (u=193), 15 rain for pancreatobiliary ( n = 160) and 12 rain for colorectal indications (U=44). Sedation, using a mean o f 7.5 mg o f midazolam, was administered in 89% of all upper GI tract, 94% of pancreatobiliary and only 3% of colorectal indications. 61% of patients could not remember the EUS examinations, and only 5% found it uncomfortable or not acceptable. 82 % of patieots would repeat the examination, of those 85 % with the same amount of sedation. In comparison to their prior endoscopic experience, 43% of patients found it equal, 29% superior and 16% worse (no opinion in 12%). No complications occured in any of the patients 9Conclusion: EUS is a safe and well tolerated examination, whioch calt be performed in a reasonable time given sufficient experience of the examiners and a large percentage of indications classified as useful. Further studies have to show whether a lower degree of sedation i s possible without loss of patient acceptance.
r
]'556
EVALUATION OF SUBMUCOSAL LESIONS: DOES EUS DIRECT MANAGEMENT. AE Ranisarda and R Kim. University of Pittsburgh, PA Management and diagnosis of GI luminal submucosal (SM) lesions and thickened gastric folds (TGF) are controversial. Endoscopic biopsy and conventional radiographic techniques are often nondiagnostic. EUS provides improved sensitivity for the diagnosis of these lesions. Aims: To determine if EUS alters the management or clinical outcome of patients with SM lesions or TGF. M e t h o d s : Endoscopy, pathology, surgical and outpatient records were reviewed from 41 patients undergoing EUS for SM lesions or TGF. Telephone interviews and chart reviews were performed to determine the clinical outcome of management of these patients. Results:
ENDOSCOPIC ULTRASOUND IS LESS A C C U R A T E IN P A N C REATIC CANCER STAGING THAN PREVIOUSLY THOUGHT: A B L I N D A N A L Y S I S O F V I D E O T A P E S T.R0seh, H.J.Ditller,R. Lorenz, K.Slrobei, H.D.Allescher, J.R.Roder, J.R.Siewert, H.H6fler, P. Gerhardt, M. Classen, Depts. of Internal Medicine II, Radiology, Pathology and Surgery, Technical University of Munich, Germany
EUS Findings
Mucosal (M) Lesions N=8 ~3ubmucosal Lesions N=7 Muscularis Propria (MP) Lesions N=9 ~Extrinsic Lesions N=5 Vascular Lesions N=I
Management Observation Polypectomy* H2B* Observe-1, Resect-2* Observation Surgery* Observe-6, Surgery-l* Surgery* Leiomyosarcoma- 1 Submucosal fibrosis - 1 Surgery Observe-2*Surgery-2* Pseudocyst - 4 I Surger~r Pancreatic Ca - 1 Gastric Varices - 1 Liver Evaluation* MM
Dia~n0sis Leiomyoma - 3 Polyp (not varices)- 3 Inflammation - 2 Pancreatic Rest - 3 Lipoma - 3 Metastasis - 1 Leiomyoma - 7
Diagnosis I H2B Intervention Inflammation - 2 i Polypectomy* Adenomatous - 1 Chemotherapy* Lymphoma - 1 Leiom~,oma - 2 Observe- 1 ,Surgery- 1* Linitis Plastica - 2 Surgery* Normal - 3 None EUS was management felt to be valuable in directing management in 90% (37141). EUS misdirected the management of 1 lesion (2%) felt to be a leiomyoma by EUS, but found to have SM fibrosis at pathology. All patients managed expectantly are alive without development of complications at 1-18 months of follow-up. Conclusions: 1) EUS is valuable in directing the clinical management of SM lesions and TGF. 2) Cost-effective strategies for the evaluation of these lesions, limiting the use of radiographic and multiple endoscopic examinations, should incorporate the early utilization of EUS. EUS Findings SVI Thickening N=3 SM Thickenin$ N=I NIP Thickening N=2 A l l layers N= 2 Normal N= 3
VOLUME 43, NO. 4, 1996
Background." Previous studies showing very high accuracy rates of endoscopic ulwasunography (EUS) in pancreatic cancer staging could not be confirmed in other trials. We therefore used completely blind videotape analysis of pancreatic head cancer (PHC) patients to reassess this issue. Patients and Methods: 67 patients (42 male, age 41-77 years) were included whose PHC was either resected (n=37) or operatively explored (n = 9 ) or who had a positive angiography ( n = 21). Examinations had been done by 4 examiners and completely blind videotape analysis was performed by one of the authors. Results: 35 patients had portal venous infillxation (stage T3), 32 not (3 T1, 29 T2). T staging (all pts.) and N staging (37 resected tumors) was correct in 70% and 57% of cases, respectively. Using "lack of a vessel wall at the border to the PHC" as a parameter (additionally to "tumor in vascular lumen" and "complete obstruction"), the accuracy was only 70%, sensitivity and specificity being 74% and 75%, respectively. Omitring this parameter, sensitivity fell to 54 %, but specitity rose to 88 % and T staging accuracy to 78%. O f the 9 failures to detect venous invasion 2 were due to technical reasons (no instrument passage, tumor too large) and 3 due to lack of visualization of exclusive superior mesenteric vein involvement. Of the vessel negative cases, 75% had no direct tumorvessel relationship, and 9% a lack of a vesser ~vall. This was also seen in 29% of cases with vascular infiltration, and 43% of these patients had direct endosonographic evidence of tumor in the vascular lumen. Conclusions: EUS is considerably less accurate in PHC staging than previously thought; the presently used criteria seem to be partially insufficient. Combination of radial and linear EUS instruments and/or use of the Doppler may be more helpful but have to be further evaluated.
GASTROINTESTINAL ENDOSCOPY
429
~555
THE USE OF ENDOSCOPIC ULTRASONOGRAPHY TO REDUCE THE COST OF TREATING AMPULLARY TUMORS. D. Quirk, D. Rat~ner, C. Fernandez, A. Warshaw, and W. Bmgge, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA
ENDOSOPIC ULTRASONOGRAPHYIN CLINICAL PRACTICE: PERFORMANCE, COMPLICATIONS A N D PATIENT ACCEPTANCE I . RSsch. H.D. Aileseher, R. Lorenz, G. Wiilkomm, M. Classen, Department of Internal Medicine I1, Technical University of Munich, Germany
Introduction: Endoscopic ultrasonography (EUS) has been used to stage ampullary tumors The treatment for benign and malignant tumors is resection, either local excision or Whipple resection. Local excision of ampullary tumors may result in the same benefit with less morbidity, mortality, and cost. Traditional preoperative staging with CT and angiography have been unsuccessful at differentiating local from invasive tumors The purpose of this study was to deternune if EUS could aid in the selection of patients for local resection and if there was a sigmficant cost difference between the two surgical procedures. Methods: A retrospective study was conducted on 29 patients who underwent surgery for ampullary tumors between April of 1993 and August of 1995. EUS (radial-5; linear-10) was performed on 15 patients and T staging was determined by blinded interpretation Resected specimens were used to determine pathologic T staging Local disease was defined as stage T2 or less. Cost data was available on 14 patients An external cost accounting firm was used to provide the total cost of hospitalization for surgical resection. The hospitalization costs of patients in the local resection group and the Whipple group were compared. Results: Ten of the 15 patients who underwent EUS had a pathologically confirmed localized ampnilary tumor Eight of the 10 patients with localized disease were correctly staged by EUS for a sensitivity of 80%. All 8 patients staged by EUS as having local disease were confirmed with pathologic staging (positive predictive value was 100%). The median total cost for a local resection was $9,589 vs $19,752 for a Whipple resection (p < 0 003). Conclusion: EUS is an effective tool for identifying patients with localized ampullary tumors The cost of a local resection for ampullary tumors is significantlyless than that of a Whipple reseciaon.. The use of EUS to select patients for local resection is a cost effective technique in the management of patients with ampullary tumors.
Background: Endoscopic uitrasonography (EUS) has been used for a variety of indications, but little data is available about the actual performance of the examination (sedation, examination time) and about patient acceptance. Patients and Methods: In a prospective study, 397 consecutive patients (age 22-78 years) were included. Indications were classified by the three examiners according to interaafioual consensus papers into I (established), 2 (useful), 3 (potentially useful), 4 (questionable) and 5 (wrong). Premedicatlon, complications and patient acceptance (using a questionnaire) were also recorded. All out-patients were monitored in a dayclinic for a few hours after EUS. 310 ,patients agreed to answer a questionnaire after EUS when they were fully conscious. Results: The classification of indications was 1 in 34%, 2 in 10%, 3 in 39%, 4 in 1 1 % and 5 in 6% of cases. Examination time was a mean of 9 rain. for esophagogastric (u=193), 15 rain for pancreatobiliary ( n = 160) and 12 rain for colorectal indications (U=44). Sedation, using a mean o f 7.5 mg o f midazolam, was administered in 89% of all upper GI tract, 94% of pancreatobiliary and only 3% of colorectal indications. 61% of patients could not remember the EUS examinations, and only 5% found it uncomfortable or not acceptable. 82 % of patieots would repeat the examination, of those 85 % with the same amount of sedation. In comparison to their prior endoscopic experience, 43% of patients found it equal, 29% superior and 16% worse (no opinion in 12%). No complications occured in any of the patients 9Conclusion: EUS is a safe and well tolerated examination, whioch calt be performed in a reasonable time given sufficient experience of the examiners and a large percentage of indications classified as useful. Further studies have to show whether a lower degree of sedation i s possible without loss of patient acceptance.
r
]'556
EVALUATION OF SUBMUCOSAL LESIONS: DOES EUS DIRECT MANAGEMENT. AE Ranisarda and R Kim. University of Pittsburgh, PA Management and diagnosis of GI luminal submucosal (SM) lesions and thickened gastric folds (TGF) are controversial. Endoscopic biopsy and conventional radiographic techniques are often nondiagnostic. EUS provides improved sensitivity for the diagnosis of these lesions. Aims: To determine if EUS alters the management or clinical outcome of patients with SM lesions or TGF. M e t h o d s : Endoscopy, pathology, surgical and outpatient records were reviewed from 41 patients undergoing EUS for SM lesions or TGF. Telephone interviews and chart reviews were performed to determine the clinical outcome of management of these patients. Results:
ENDOSCOPIC ULTRASOUND IS LESS A C C U R A T E IN P A N C REATIC CANCER STAGING THAN PREVIOUSLY THOUGHT: A B L I N D A N A L Y S I S O F V I D E O T A P E S T.R0seh, H.J.Ditller,R. Lorenz, K.Slrobei, H.D.Allescher, J.R.Roder, J.R.Siewert, H.H6fler, P. Gerhardt, M. Classen, Depts. of Internal Medicine II, Radiology, Pathology and Surgery, Technical University of Munich, Germany
EUS Findings
Mucosal (M) Lesions N=8 ~3ubmucosal Lesions N=7 Muscularis Propria (MP) Lesions N=9 ~Extrinsic Lesions N=5 Vascular Lesions N=I
Management Observation Polypectomy* H2B* Observe-1, Resect-2* Observation Surgery* Observe-6, Surgery-l* Surgery* Leiomyosarcoma- 1 Submucosal fibrosis - 1 Surgery Observe-2*Surgery-2* Pseudocyst - 4 I Surger~r Pancreatic Ca - 1 Gastric Varices - 1 Liver Evaluation* MM
Dia~n0sis Leiomyoma - 3 Polyp (not varices)- 3 Inflammation - 2 Pancreatic Rest - 3 Lipoma - 3 Metastasis - 1 Leiomyoma - 7
Diagnosis I H2B Intervention Inflammation - 2 i Polypectomy* Adenomatous - 1 Chemotherapy* Lymphoma - 1 Leiom~,oma - 2 Observe- 1 ,Surgery- 1* Linitis Plastica - 2 Surgery* Normal - 3 None EUS was management felt to be valuable in directing management in 90% (37141). EUS misdirected the management of 1 lesion (2%) felt to be a leiomyoma by EUS, but found to have SM fibrosis at pathology. All patients managed expectantly are alive without development of complications at 1-18 months of follow-up. Conclusions: 1) EUS is valuable in directing the clinical management of SM lesions and TGF. 2) Cost-effective strategies for the evaluation of these lesions, limiting the use of radiographic and multiple endoscopic examinations, should incorporate the early utilization of EUS. EUS Findings SVI Thickening N=3 SM Thickenin$ N=I NIP Thickening N=2 A l l layers N= 2 Normal N= 3
VOLUME 43, NO. 4, 1996
Background." Previous studies showing very high accuracy rates of endoscopic ulwasunography (EUS) in pancreatic cancer staging could not be confirmed in other trials. We therefore used completely blind videotape analysis of pancreatic head cancer (PHC) patients to reassess this issue. Patients and Methods: 67 patients (42 male, age 41-77 years) were included whose PHC was either resected (n=37) or operatively explored (n = 9 ) or who had a positive angiography ( n = 21). Examinations had been done by 4 examiners and completely blind videotape analysis was performed by one of the authors. Results: 35 patients had portal venous infillxation (stage T3), 32 not (3 T1, 29 T2). T staging (all pts.) and N staging (37 resected tumors) was correct in 70% and 57% of cases, respectively. Using "lack of a vessel wall at the border to the PHC" as a parameter (additionally to "tumor in vascular lumen" and "complete obstruction"), the accuracy was only 70%, sensitivity and specificity being 74% and 75%, respectively. Omitring this parameter, sensitivity fell to 54 %, but specitity rose to 88 % and T staging accuracy to 78%. O f the 9 failures to detect venous invasion 2 were due to technical reasons (no instrument passage, tumor too large) and 3 due to lack of visualization of exclusive superior mesenteric vein involvement. Of the vessel negative cases, 75% had no direct tumorvessel relationship, and 9% a lack of a vesser ~vall. This was also seen in 29% of cases with vascular infiltration, and 43% of these patients had direct endosonographic evidence of tumor in the vascular lumen. Conclusions: EUS is considerably less accurate in PHC staging than previously thought; the presently used criteria seem to be partially insufficient. Combination of radial and linear EUS instruments and/or use of the Doppler may be more helpful but have to be further evaluated.
GASTROINTESTINAL ENDOSCOPY
429