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The Role of Endoscopic Ultrasound in the Evaluation of Barrett's Esophagus with High Grade Dysplasia or Intramucosal Carcinoma in the Surgical Patient
Abstracts
W1269 The Role of Endoscopic Ultrasound in the Evaluation of Barrett’s Esophagus with High Grade Dysplasia or Intramucosal Carcinoma in the Surgical Patient Randall Meisner, Deepak Gopal, Terrence Frick, Tracey Weigel, Patrick Pfau Background: The accuracy and clinical utility of endoscopic ultrasound (EUS) in staging esophageal cancer is well established. The accuracy of EUS and its effect on the clinical management of patients with Barrett’s esophagus (BE) and high grade dysplasia (HGD) or intramucosal carcinoma is not well established. Methods: Retrospective review of all patients who underwent EUS with standard 7.5 and 12 mHz Olympus radial echoendoscope for the evaluation of BE with HGD or intramucosal carcinoma without an endoscopic mass lesion over a 38 month period. Patients were evaluated for EUS T and N stage. EUS T and N stage was compared with surgical and pathologic staging. Management of patients was recorded and if EUS findings affected patient management. Results: EUS was perfomed on 20 patients. EUS stage was as follows T0 (10); T1 (9); T2 (1). All patients were EUS stage N0 with no EUS evidence of malignant appearing lymphadenopathy. No celiac axis lymph nodes were visualized. Surgical pathology from 16 esophagectomy specimens showed 1 patient with Barrett’s metaplasia, 4 patients with low grade dysplasia, 6 patients with HGD, and 5 patients with carcinoma. Surgical T stage was as follows: T0 (11); T1 (5); T2 (0). All patients were surgical N0 with no malignant lymph nodes found in any patient at time of surgery. EUS T stage accuracy was (81%), N stage accuracy (100%). 16 patients underwent esophagectomy; 1 patient underwent PDT due to co-morbidities; 1 was lost to follow-up; in 2 patients surgery is pending. EUS staging did not change planned surgery in any patient. Conclusion: 1) EUS is accurate in staging patients with HGD or intramucosal CA in the esophagus 2) In patients with HGD or intramucosal carcinoma, EUS did not detect any unsuspected lymph node involvement or extension of tumor through the esophageal wall. 3) The surgically fit patient with BE and HGD or intramucosal carcinoma may be able to proceed directly to esophagectomy without EUS staging.
W1271 EUS-Guided Transbulbar Rendezvous After Failed ERCP: A Report of 2 Cases Jan-Werner Poley, Jelle Haringsma, Ernst J. Kuipers Introduction: ERCP is highly successful in removal of common bile duct (CBD) stones. However, in certain cases ERCP can be difficult or impossible to perform, e.g. in case of duodenal diverticula, or after surgical interventions. Percutaneous and surgical approaches are associated with considerable morbitidy and are technically demanding. We performed an EUS guided rendez-vous technique in 2 patients with non-dilated ducts in whom both ERCP and PTC failed, and in whom surgery was contra-indicated. Cases: Patient 1 was a 82-year old male with severe comorbidity who developed cholangitis. MRCP showed choledocholithiasis. ERCP performed elsewhere failed repetitively as the papilla could not be located due to duodenal diverticula. He was referred to our institution. ERCP again failed. Percutaneous intervention was unsuccessful because of non-dilated intrahepatic ducts. We decided to use an EUS guided approach. The CBD was punctured from the duodenal bulb with a 19G needle, a cholangiogram was obtained and a guidewire was passed through the papilla. The EUS endoscope was exchanged for a regular side-viewing endoscope and the guidewire was picked up from the orifice in the diverticulum. Endoscopic sphincterotomy was performed with subsequent complete stone extraction. The same technique was used in 67-year old male patients with cholangitis due do CBD stones 6 weeks after surgery for a mitral valve prosthesis. Again ERCP was unsuccessfull for anatomical reasons and PTC failed because of non-dilated intrahepatic bile ducts. Both patients showed a rapid, uneventful recovery. Conclusions: to our knowledge this is the first report of successful, completely endoscopic procedures after EUS-rendez vous for choledocholithiasis. In experienced hands this technique is a possible alternative to percutaneous or surgical approaches in patients with choledocholithiasis in whom ERCP is not possible, especially in patients with non-dilated ducts.
W1270 Evolving Role of Interventional Endoscopic Ultrasound (EUS) Cyrus Piraka, Mainor Antillon, Raj J. Shah, Nida Awadallah, Yang K. Chen Background: EUS is established in the diagnosis and staging of GI malignancies. Therapeutic EUS is evolving and includes celiac plexus block and pseudocyst (PC) drainage. We report our experience with 6 indications for therapeutic EUS. Results: (1) Hematoma drainage: 47 yo F with pain and fever 3-1/2 wk post-LOA. CT: perirectal fluid collection. EUS: 50 ! 43 mm cystic mass with septations. EUS-guided needle evacuation obtained fluid consistent with old hematoma. Cytology and cultures - negative. Fever and pain subsided. CT at 4 wk - resolved. (2) Choledochoduodenostomy: 61 yo M with jaundice and pancreatic mass on CT. EUS/ FNA - 68 ! 40 mm adenocarcinoma invading duodenum, superior mesenteric vein, splenoportal confluence. Transpapillary stenting failed due to mass in ampulla/ duodenum. Guidewire (GW) placed through echoendoscope from bulb into bile duct (BD) above obstruction. GW would not pass antegrade across the stricture/ papilla for rendezvous. EUS-guided choledochoduodenostomy and stenting was done at the same session, with excellent biliary drainage. (3) Pancreatic rendezvous: 63 yo F with pain, chronic pancreatitis, and stones obstructing the ventral pancreatic duct (PD). Cannulation of major/minor orifices failed. EUS-guided transgastric access into main PD was followed by advancement of GW across the minor papilla. The GW was retrieved using the duodenoscope, followed by minor papillotomy and pancreatoscopy-electrohydraulic lithotripsy. ERP at 6 months confirmed stone clearance. (4) Cyst-esophagostomy: 60 yo M with symptomatic 20 ! 10 cm PC. Anatomic considerations led to EUS-guided cystesophagostomy and stenting, with complete drainage and no recurrence at 5 months. (5) Gastropancreatic stenting: 58 yo M with symptomatic 58 ! 48 mm PC and amylaserich pleural effusion. EUS cyst gastrostomy successful but after 6 wk pt returned with dyspnea, effusion and pancreatic ascites. ERP - stenosis in the head and contrast leak into pleural space. ERP transpapillary GW and EUS-guided transgastric GW failed to traverse PD stricture. Pancreaticogastrostomy and stenting was performed. Effusion and ascites nearly completely resolved on CT at 2 months and pt has been symptom-free for 13 months. (6) Pelvic abscess drainage: 61 yo M with 70 ! 50 mm diverticular abscess near rectosigmoid. EUS-guided drainage and stenting performed, followed by sigmoid colectomy with primary anastomosis 23 days later, avoiding a 2-stage surgery. Conclusion: EUS has an expanding therapeutic role.
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W1272 360 Radial Electronic Echoendoscope: First Clinical Results Benedicte Prost, Ilham Serraj, Christine Lefort, Bertrand Napoleon, Pierre-Edouard Queneau, Jean-Claude Cenni, Bertrand Pujol, Jean-Christophe Souquet, Thierry Ponchon Introduction: Initial technology for diagnosis EUS was 360 radial mechanical. Up to now electronic transducer could not replace mechanical probe for 360 analysis. We describe our experience with a radial echoendoscope prototype which combines both electronic technology and 360 scanning range. Material and Methods: The 360 scanning electronic radial EUS scope provided by Olympus Co. and connected with Aloka echographe allows doppler and harmonic analyzis. The frequency is ajustable at 5, 6, 7.5 and 10 MHz. The distal end has a diameter of 14.2 mm and a longer rigid section than the mechanical probe. Twenty-four patients (14 men and 10 women) underwent EUS with this new EE in our unit. Mean age was 61,1 G15,3 . Indications were stagging and follow up of oesophageal carcinoma (3), cardial adenocarcinoma (2), gastric tumor (4), rectal tumor (2), diagnosis or follow up of pancreatic cysts (3), stagging of pancreatic mass (3), acute pancreatis (1) and others (5). Examinations were reviewed by 6 operators. Results: All examinations were complete and permitted satisfactory diagnosis and staging. EUS images appeared with an improved and more accurate resolution for all users in comparison to radial mechanical probe, wathever the site. Contrast was found reinforced, allowing better delineation of the different structures. For a same frequency level, penetration of US resulted in better definition at the periphery of the screened field. Furthermore, images were not disturbed by artefacts or parasites. Manoeuvrability of the probe was satisfactory, but the diameter and the length of the rigid section of the probe impeded in some cases esophageal introduction and genu superius passage. Conclusions: New electronic radial EUS scope appears very promising: it combines high quality of images and easy to use 360 scanning. Potential durability of the electronic probe could be another key factor but needs to be demonstrated.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB297
W1269 The Role of Endoscopic Ultrasound in the Evaluation of Barrett’s Esophagus with High Grade Dysplasia or Intramucosal Carcinoma in the Surgical Patient Randall Meisner, Deepak Gopal, Terrence Frick, Tracey Weigel, Patrick Pfau Background: The accuracy and clinical utility of endoscopic ultrasound (EUS) in staging esophageal cancer is well established. The accuracy of EUS and its effect on the clinical management of patients with Barrett’s esophagus (BE) and high grade dysplasia (HGD) or intramucosal carcinoma is not well established. Methods: Retrospective review of all patients who underwent EUS with standard 7.5 and 12 mHz Olympus radial echoendoscope for the evaluation of BE with HGD or intramucosal carcinoma without an endoscopic mass lesion over a 38 month period. Patients were evaluated for EUS T and N stage. EUS T and N stage was compared with surgical and pathologic staging. Management of patients was recorded and if EUS findings affected patient management. Results: EUS was perfomed on 20 patients. EUS stage was as follows T0 (10); T1 (9); T2 (1). All patients were EUS stage N0 with no EUS evidence of malignant appearing lymphadenopathy. No celiac axis lymph nodes were visualized. Surgical pathology from 16 esophagectomy specimens showed 1 patient with Barrett’s metaplasia, 4 patients with low grade dysplasia, 6 patients with HGD, and 5 patients with carcinoma. Surgical T stage was as follows: T0 (11); T1 (5); T2 (0). All patients were surgical N0 with no malignant lymph nodes found in any patient at time of surgery. EUS T stage accuracy was (81%), N stage accuracy (100%). 16 patients underwent esophagectomy; 1 patient underwent PDT due to co-morbidities; 1 was lost to follow-up; in 2 patients surgery is pending. EUS staging did not change planned surgery in any patient. Conclusion: 1) EUS is accurate in staging patients with HGD or intramucosal CA in the esophagus 2) In patients with HGD or intramucosal carcinoma, EUS did not detect any unsuspected lymph node involvement or extension of tumor through the esophageal wall. 3) The surgically fit patient with BE and HGD or intramucosal carcinoma may be able to proceed directly to esophagectomy without EUS staging.
W1271 EUS-Guided Transbulbar Rendezvous After Failed ERCP: A Report of 2 Cases Jan-Werner Poley, Jelle Haringsma, Ernst J. Kuipers Introduction: ERCP is highly successful in removal of common bile duct (CBD) stones. However, in certain cases ERCP can be difficult or impossible to perform, e.g. in case of duodenal diverticula, or after surgical interventions. Percutaneous and surgical approaches are associated with considerable morbitidy and are technically demanding. We performed an EUS guided rendez-vous technique in 2 patients with non-dilated ducts in whom both ERCP and PTC failed, and in whom surgery was contra-indicated. Cases: Patient 1 was a 82-year old male with severe comorbidity who developed cholangitis. MRCP showed choledocholithiasis. ERCP performed elsewhere failed repetitively as the papilla could not be located due to duodenal diverticula. He was referred to our institution. ERCP again failed. Percutaneous intervention was unsuccessful because of non-dilated intrahepatic ducts. We decided to use an EUS guided approach. The CBD was punctured from the duodenal bulb with a 19G needle, a cholangiogram was obtained and a guidewire was passed through the papilla. The EUS endoscope was exchanged for a regular side-viewing endoscope and the guidewire was picked up from the orifice in the diverticulum. Endoscopic sphincterotomy was performed with subsequent complete stone extraction. The same technique was used in 67-year old male patients with cholangitis due do CBD stones 6 weeks after surgery for a mitral valve prosthesis. Again ERCP was unsuccessfull for anatomical reasons and PTC failed because of non-dilated intrahepatic bile ducts. Both patients showed a rapid, uneventful recovery. Conclusions: to our knowledge this is the first report of successful, completely endoscopic procedures after EUS-rendez vous for choledocholithiasis. In experienced hands this technique is a possible alternative to percutaneous or surgical approaches in patients with choledocholithiasis in whom ERCP is not possible, especially in patients with non-dilated ducts.
W1270 Evolving Role of Interventional Endoscopic Ultrasound (EUS) Cyrus Piraka, Mainor Antillon, Raj J. Shah, Nida Awadallah, Yang K. Chen Background: EUS is established in the diagnosis and staging of GI malignancies. Therapeutic EUS is evolving and includes celiac plexus block and pseudocyst (PC) drainage. We report our experience with 6 indications for therapeutic EUS. Results: (1) Hematoma drainage: 47 yo F with pain and fever 3-1/2 wk post-LOA. CT: perirectal fluid collection. EUS: 50 ! 43 mm cystic mass with septations. EUS-guided needle evacuation obtained fluid consistent with old hematoma. Cytology and cultures - negative. Fever and pain subsided. CT at 4 wk - resolved. (2) Choledochoduodenostomy: 61 yo M with jaundice and pancreatic mass on CT. EUS/ FNA - 68 ! 40 mm adenocarcinoma invading duodenum, superior mesenteric vein, splenoportal confluence. Transpapillary stenting failed due to mass in ampulla/ duodenum. Guidewire (GW) placed through echoendoscope from bulb into bile duct (BD) above obstruction. GW would not pass antegrade across the stricture/ papilla for rendezvous. EUS-guided choledochoduodenostomy and stenting was done at the same session, with excellent biliary drainage. (3) Pancreatic rendezvous: 63 yo F with pain, chronic pancreatitis, and stones obstructing the ventral pancreatic duct (PD). Cannulation of major/minor orifices failed. EUS-guided transgastric access into main PD was followed by advancement of GW across the minor papilla. The GW was retrieved using the duodenoscope, followed by minor papillotomy and pancreatoscopy-electrohydraulic lithotripsy. ERP at 6 months confirmed stone clearance. (4) Cyst-esophagostomy: 60 yo M with symptomatic 20 ! 10 cm PC. Anatomic considerations led to EUS-guided cystesophagostomy and stenting, with complete drainage and no recurrence at 5 months. (5) Gastropancreatic stenting: 58 yo M with symptomatic 58 ! 48 mm PC and amylaserich pleural effusion. EUS cyst gastrostomy successful but after 6 wk pt returned with dyspnea, effusion and pancreatic ascites. ERP - stenosis in the head and contrast leak into pleural space. ERP transpapillary GW and EUS-guided transgastric GW failed to traverse PD stricture. Pancreaticogastrostomy and stenting was performed. Effusion and ascites nearly completely resolved on CT at 2 months and pt has been symptom-free for 13 months. (6) Pelvic abscess drainage: 61 yo M with 70 ! 50 mm diverticular abscess near rectosigmoid. EUS-guided drainage and stenting performed, followed by sigmoid colectomy with primary anastomosis 23 days later, avoiding a 2-stage surgery. Conclusion: EUS has an expanding therapeutic role.
www.mosby.com/gie
W1272 360 Radial Electronic Echoendoscope: First Clinical Results Benedicte Prost, Ilham Serraj, Christine Lefort, Bertrand Napoleon, Pierre-Edouard Queneau, Jean-Claude Cenni, Bertrand Pujol, Jean-Christophe Souquet, Thierry Ponchon Introduction: Initial technology for diagnosis EUS was 360 radial mechanical. Up to now electronic transducer could not replace mechanical probe for 360 analysis. We describe our experience with a radial echoendoscope prototype which combines both electronic technology and 360 scanning range. Material and Methods: The 360 scanning electronic radial EUS scope provided by Olympus Co. and connected with Aloka echographe allows doppler and harmonic analyzis. The frequency is ajustable at 5, 6, 7.5 and 10 MHz. The distal end has a diameter of 14.2 mm and a longer rigid section than the mechanical probe. Twenty-four patients (14 men and 10 women) underwent EUS with this new EE in our unit. Mean age was 61,1 G15,3 . Indications were stagging and follow up of oesophageal carcinoma (3), cardial adenocarcinoma (2), gastric tumor (4), rectal tumor (2), diagnosis or follow up of pancreatic cysts (3), stagging of pancreatic mass (3), acute pancreatis (1) and others (5). Examinations were reviewed by 6 operators. Results: All examinations were complete and permitted satisfactory diagnosis and staging. EUS images appeared with an improved and more accurate resolution for all users in comparison to radial mechanical probe, wathever the site. Contrast was found reinforced, allowing better delineation of the different structures. For a same frequency level, penetration of US resulted in better definition at the periphery of the screened field. Furthermore, images were not disturbed by artefacts or parasites. Manoeuvrability of the probe was satisfactory, but the diameter and the length of the rigid section of the probe impeded in some cases esophageal introduction and genu superius passage. Conclusions: New electronic radial EUS scope appears very promising: it combines high quality of images and easy to use 360 scanning. Potential durability of the electronic probe could be another key factor but needs to be demonstrated.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB297