- Email: [email protected]
Tu1551 Accuracy of Endoscopic Ultrasonography in Preoperative T Staging of an Early Gastric Cancer
Abstracts
Tu1548 Metallic Stent Deployment in Endosonography-Guided Biliary Drainage: Long Term Follow-up Results in Patients With BilioEnteric Anastomosis Jun Horaguchi*, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Kei Ito, Shinsuke Koshita, Yoshihide Kanno, Takahisa Ogawa, Kaori Masu Sendai City Medical Center, Sendai, Japan Background: Though reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few case series have been reported on deployment of a self-expandable metal stent (SEMS) and its long-term results. Aim: To evaluate the safety and efficacy of SEMS deployment in ESBD. Patients and Methods: Of 40 patients who underwent ESBD due to difficult biliary cannulation in ERCP during the period from January 2007 to May 2011 in our department, 20 patients with unresectable malignant biliary obstruction in whom ESBD with a SEMS had been attempted were included. The male to female ratio was 9:11 and their average age was 73 years old. Puncture of the bile duct was performed with a 19G needle under endosonographic guidance. After dilation of the puncture tract, a plastic stent or SEMS was placed to bridge the intra-/ extrahepatic bile duct and the gastrointestinal tract. SEMS was deployed in the first session with the one-step technique or in the second session with replacement of a plastic stent with a SEMS. The technical success, early and late complications related to SEMS deployment, and stent patency of SEMS were evaluated. Results: One-step SEMS deployment was attempted in 6 patients, and SEMS deployment with stent exchange in 14, all of which were successful. In all patients who had undergone deployment of a SEMS with the one-step technique, the SEMS was deployed to the extrahepatic bile duct via the duodenum. In 9 of the 14 patients who had undergone stent exchange, the SEMS was deployed in the intrahepatic bile duct in 3 and in the extrahepatic bile duct in 6 in a bilioenteric anastomosis fashion. The other 5 patients who had initial plastic stent deployment in the intrahepatic bile duct underwent stent exchange for SEMS with antegrade deployment across the biliary stenosis. No complications relevant to the procedures were encountered in all patients. Late complications occurred in 3 of 15 patients who underwent deployment of SEMS in a bilio-enteric anastomosis fashion (stent obstruction in 2 and reflux cholangitis in 1). The mean survival and the mean stent patency period were 266 days and 279 days, respectively. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, SEMS can be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.
Tu1549 Practice Patterns in FNA Technique by U.S. Endosonographers: A Survey Analysis Christopher J. Dimaio*1, Seth A. Gross2, Jonathan Buscaglia3, ADAM J. Goodman4, Michelle K. Kim1, Shireen A. Pais5, Uzma D. Siddiqui6, Harry R. Aslanian6, Felice Schnoll-Sussman7, Sammy Ho8, Amrita Sethi9, David H. Robbins10, Satish Nagula3 1 Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY; 2Section of Gastroenterology, Norwalk Hospital, Norwalk, CT; 3 Division of Gastroenterology and Hepatology, Stony Brook University Medical Center, Stony Brook, NY; 4Division of Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY; 5 Gastroenterology & Hepatobiliary Diseases, New York Medical College, Valhalla, NY; 6Section of Digestive Diseases, Yale School of Medicine, New Haven, CT; 7Division of Gastroenterology & Hepatology, NewYorkPresbyterian Hospital/Weill Cornell Medical Center, New York, NY; 8 Gastroenterology & Liver Diseases, Montefiore Medical Center, Bronx, NY; 9Division of Digestive and Liver Diseases, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY; 10 Division of Gastroenterology, Lenox Hill Hospital, New York, NY Background: EUS-FNA has become a mainstay in the evaluation of various GI diseases. Despite its widespread use, little is known about the preferred FNA techniques used by practitioners. Aims: To ascertain FNA techniques by endosonographers with varying levels of experience and practice environments. Methods: GI physicians performing EUS-FNA in the U.S. were identified from a list of providers assembled by a major FNA needle manufacturer. E-mail addresses were queried via AGA, ASGE, & ACG membership directories. Subjects were e-mailed and asked to complete an anonymous electronic survey assessing their FNA practices. Results: A total of 681 practitioners were contacted; 216 (32%) completed the survey. Majority of respondents (54%) had completed a 4th year fellowship in EUS. Nearly half (48%) identified themselves as academic/ university-based practitioners, while 45% were community-based. All age ranges were equally represented. High-volume FNA (⬎150/year) was noted in 35% respondents, medium-volume FNA (75-150/year) in 37%, and low-volume FNA (⬍75/year) in 28%. The 22 gauge needle was the preferred needle size for initial FNA of solid pancreatic mass (63%), submucosal mass (72%) and lymph nodes (51%), with either 10-20 (50%) or 6-10 (37%) needle throws per pass. Most respondents used a stylet on the initial pass (92%) and on subsequent passes
www.giejournal.org
(83%). Suction was routinely used for solid lesions (86%) and less often for lymph nodes (67%). Rapid on-site evaluation of cytology (ROSE) was used by 76% of respondents. If ROSE is unavailable, 69% perform 3-5 needle passes. If inadequate specimen determined by ROSE, 42% cease and await results of cell block, while 23% changed to a core biopsy needle. If bloody specimen, 48% repeat FNA but without suction, while 24% repeat FNA with no changes. If final cytology non-diagnostic, 54% repeat EUS-FNA and consider using a core needle; 17% repeat EUS-FNA alone; 9% refer for percutaneous biopsy; 4% refer for surgical biopsy. If adequate tissue is not obtained via ROSE, low-volume EUS physicians (⬍150/year) were more likely to await results of cell-block compared to high-volume (43.1% vs. 29.3%), and high-volume EUS physicians were more likely to use a core needle (21.3% vs. 2.0%) (p ⫽ 0.024). If final cytology is nondiagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle (60% vs. 31%), and low volume physicians were more likely to refer for either surgical or percutaneous biopsy, (33% vs. 5%) (p ⬍ 0.0001). Academic physicians were more likely to repeat FNA with a core needle (67%) compared to community physicians (39%, p ⬍ 0.001). Conclusions: There is moderate variation in EUS-FNA practices among EUS practitioners. Significant differences appear to be related to EUS volume & procedural environment.
Tu1550 Usefulness of EUS-FNA for GI Tract Lesions Ryoji Miyahara*1, Kohei Funasaka2, Kazuhiro Furukawa2, Keiichi Sakamaki2, Hidezumi Tatematsu2, Issei Tsurudome2, Fumiko Yamamoto2, Ippei Matsuzaki2, Eizaburo Ohno1, Hiroki Kawashima2, Akihiro Itoh2, Naoki Ohmiya2, Yoshiki Hirooka1, Osamu Watanabe2, Osamu Maeda2, Takafumi Ando2, Hidemi Goto2,1 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology, Nagoya University, graduate school of medicine, Nagoya, Japan Background and Study Design: To obtain accurate histopathological diagnosis of submucosal tumors (SMTs), EUS-FNA may be most suitable procedure. However, reports which examined usefulness and safety of EUS-FNA for GI tract lesions are still limited. In this study, we evaluated the usefulness of EUS-FNA for GI tract lesions from our experience. Patients and Methods: In our institution, we perform EUS-FNA for SMTs and lymph nodes which exist close to GI tarct to obtain accurate histopathological diagnosis for determining therapeutic strategy. We evaluated consecutive 258 cases from August 1994 to March 2011 retrospectively, involving 27 esophagus SMTs, 38 lymph nodes, 162 gastric SMTs, 11 duodenum SMTs, 18 colonic SMTs. Results: 1. A total of 258 patients underwent EUS-FNA(range 2-6 passes). We could obtain enough tissue in 88.8% of cases. Cases of inadequate specimens showed calcification and relatively small diameter (average; 14.6mm) in EUS images. 2. Pathological diagnosis of EUS-FNA were 11 leiomyoma and 4 GISTs in esophagus, 44 leiomyomas, 92 GISTs in stomach, 9 adenocarcinomas and 1 GIST in colon, 31 carcinomas and 5 infections in lymph nodes and othres. Compared diagnosis of EUS-FNA with those of surgical operation, the rate of accurate diagnosis of EUS-FNA was 93.3% in 90 cases which we performed both EUS-FNA and operation. 3. The rate of tissue sampling and accurate diagnosis were 81.4% and 100% in esophagus, 91.4% and 88.8% in stomach, 88.9% and 100% in colon, 86.8% and 100% in lymph node, respectively. 4. Only one patient had local peritonitis without seeding after EUS-FNA. 5. In 38 cases of GISTs, we stained tissues from EUS-FNA and surgical operation immunohistochemically with Ki-67 to determine the degree of malignancy. The accuracy of diagnosis of EUS-FNA was 81.6% in Ki-67 LI. Conclusion: We could obtain accurate diagnosis for SMTs and swelling lymph nodes in safety using EUS-FNA procedure.
Tu1551 Accuracy of Endoscopic Ultrasonography in Preoperative T Staging of an Early Gastric Cancer Denis Gusev*, Alexey A. Gvozdev, Sergey V. Kashin Yaroslavl regional cancer hospital, Yaroslavl, Russian Federation Background: Development of the advanced endoscopic therapeutic methods (EMR and ESD) of an early gastric cancer (EGC) treatment has increased the role of the endoscopic ultrasonography (EUS). EUS procedure has been providing in the Endoscopy dept. of Yaroslavl regional cancer hospital since 2006. Aim: To evaluate the diagnostic accuracy of EUS in the preoperative T staging of early gastric cancer. Methods: Sixty-seven patients with verified EGC (42M/25F, age: 47-87, mean age 67,9) were underwent esophagogastroduodenoscopy and probe EUS between 2006-2010. According to the PEC (2002) type 0-Ips was detected in 13,4% (9), type 0-IIa - 25,4% (17), type 0-IIa/c - 49,2% (33), type 0-IIb - 0, type 0-IIc - 6% (4), type 0-IIc/IIa - 6% (4). Olympus EU-M60 echo video system with MAJ-935 ultrasound probe imaging linear scanning transducer (20 MHz) were employed. EUS staging procedures for EGC depth of invasion (T stage) were performed according to the nine-layer structure of the gastric wall (1). EUS image of the fifth echo-layer of the gastric wall (submucosal) was accessed by
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB443
Abstracts
following criteria: 1) no changes, 2) unclear, 3) multiple echo-free spots, 4) budding sign, 5) irregular narrowing (2). 88% (n⫽58) patients underwent endoscopic treatment and 12% (n⫽9) patients - surgery. Diagnostic accuracy of EUS for T staging of the EGC was determined by comparing preoperative EUS with subsequent postoperative histopathology findings. Results: Depending on the growth of EGC within the mucosal layer diagnostic accuracy of EUS was 93%, within submucosal layer - 66%, within muscular layer - 66%. The overall diagnostic accuracy of EUS in preoperative determination of EGC depth of invasion was 75%. Depending on the type of the EGC accuracy of EUS was varying: type 0-Ips - 78%, type 0-IIa - 87,5%, type 0-IIa/c - 78%, type 0-IIb - 0, type 0-IIc - 75%, type 0-IIc/IIa - 75%. Predominant location and distribution of the EGC in the stomach were in the antrum - 50%, corpus (lower part - 16,5%, middle part - 9%, upper part - 9%), angle of stomach - 10,6%, cardia - 5%. The rates for overstaging and understaging were 20% and 5%, respectively. Conclusion: EUS is a useful diagnostic method for preoperative staging of EGC for T criteria. However, EUS tended to overstage T criteria, and misdiagnosis increases with depth of tumor invasion. The least accurate EUS was at type 0-IIc and type 0-IIc/IIa. The main reasons of misdiagnosis were biopsy effect, wrong interpretation of the submucosal layer, peristaltic movements and perifocal inflammatory changes.
Tu1552 Comparative Study of Sample Adequacy of 25G vs. 22G Needle in Endoscopic Ultrasound (EUS) Guided Fine Needle Aspirate (FNA) of Solid Lesions Aravinth U. Murugananthan*, Thai P. Hong, Robert Chen Gastroenterology, Western Health, Melbourne, VIC, Australia Background: Optimal needle size in achieving greatest diagnostic yield from EUS- guided FNA remains unclear. Aim: We prospectively compared sample adequacy and safety of FNA of solid lesions between 25G and 22G needle at two tertiary centres. Method: Prospective data from two sites was collected between November 2008 and November 2011. A single operator alternated on a case-by-case basis between a 25G and 22G needle. A cytopathologist was present to assess adequacy of sample. The operator could switch needle size if required. Results: 152 patients undergoing 165 FNA were analysed (42m/30f, mean age 59). 76 patients had FNA with a 22 F needle and 76 with the 25F needle. Indications for EUS and FNA were pancreatic lesions 43%, lymph node enlargement 28%, biliary tract lesions 16%, submucosal lesion 8% and adrenal mass 1% and others 4%. Overall sample adequacy was 83.03% Adequacy per needle was 86.7% (22G) vs. 79.2% (25G), p⫽0.22 Fischer’s Exact test. The number of passes used in successful FNA was higher with use of the 25G needle compared with the 22G needle. (2.42 0.11 SEM vs. 1.962 0.15 SEM, p⫽0.015, ttest). In particular the use of a 25G needle had a higher number of passes in pancreatic lesions compared with the 22G needle (2.580.16 SEM vs. 1.940.14, p⫽0.004, t-test).There was no difference in adequacy between the needle sizes for each type of lesion sampled (Table 1). Two needle exchanges (25G to a 22G) occurred. One complication of local site bleeding occurred (22G) that settled during the test. Conclusion: We show no difference in sample adequacy between the two needle sizes. Use of a 25G results is associated with a higher number of passes in pancreatic FNA. Both needle sizes appear safe/ Operator choice and ease of passage of needle into anatomical location may also have influence choice of needle. Table 1. Sample adequacy per site of lesion
Lesion Site Lymph node Biliary tract lesion Pancreatic lesion Submucosal Lesion
22G 25G Adequate Inadequate Adequate Inadequate Fischer’s Sample Sample Sample Sample Exact Test 19 9 33 4
4 2 3 2
20 11 33 2
3 4 2 5
NS NS NS NS
Tu1553 Endoscopic Ultrasound of the Colon Can Differentiate Between Crohn‘S Disease and Ulcerative Colitis and Reliably Quantifies the Degree of Inflammation - a Prospective, Blinded, and Controlled Comparative Study Mark Ellrichmann*1, Johannes Bethge1, Susanna Nikolaus1, Alexander Arlt1, Tanja Kuehbacher1, Stefan Schreiber1, Perdita Wietzke-Braun1, Wolfram Klapper2, Annette Fritscher-Ravens1 1 Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany; 2Department of Pathology, Universityhospital Schleswig-Holstein, Campus Kiel, Kiel, Germany Introduction: The prognosis of acute IBD is dependent on the severity of
inflammatory changes. To date this is evaluated by clinical criteria and endoscopic IBD scores, which do not assess changes of the entire gastrointestinal(GI)-wall. Recent developments in EUS might now allow objective differentiation between ulcerative colitis (UC) and Crohn‘s disease (CD) and quantification of the grade of inflammation which would provide a more precise measure of disease state and help judge success of treatment. Aim:To study prospectively the GI-wall and it’s layers with EUS in a blind, controlled, comparative manner for possible differentiation between UC/CD and quantification of the degree of inflammation. Methods: After IRB approval consecutive patients with either active/inactive CD, UC or healthy controls (HC) were examined using a forward-viewing radial echoendoscope. Mucosal(M), submucosal(SM) and total wall-thickness (TWT) were investigated by EUS in the mid sigmoid colon. A second examiner, blinded to the result of the colonoscopy, categorized the disease seen on EUS. EUS results were compared to macroscopic IBD scores (Baron-score for UC; SES-CD-score for CD). Histological inflammation scores served as gold standard. Results: In 61 HC there was clear differentiation of the different layers of the GI wall and a TWT(1.71⫾0.02mm) that was significantly thinner than in patients with acute IBD (n⫽52; TWT 3.51⫾0.15mm; p⬍0.001); no significant difference between UC/CD (p⫽0.06). In patients with acute UC significant thickening of the mucosa was observed but nearly normal SM. In acute CD significant thickening of the submucosal layer was seen with nearly normal M (MUC⫽2.08⫾0.11mm vs. MCD⫽1.32⫾0.17mm, p⫽0.0001; SMUC⫽1.01⫾0.08mm vs. SMCD⫽2.01⫾0.22mm, p⫽0.0001). In patients with UC Baron score and in CD SES-CD score TWT correlated in a highly significant manner (r⫽0.65; p⬍0.001 and r⫽0.76 ; p⬍0.001, respectively). In UC there was a significant correlation between TWT, histological activity scores (p⬍0.006) and the grade of inflammation (p⬍0.02). In CD there was a significant correlation between activity scores, grade of inflammation and TWT on EUS (p⬍0.001). Two patients with UC were re-examined 7 days after first dose of a TNF-alpha antagonist. Colonoscopy showed no macroscopic changes compared to the examination prior to therapy. On EUS mean TWT was reduced to 2.3mm, indicating a marked response to therapy. Discussion: EUS measurement of TWT was highly predictive of the level of inflammation in patients with acute IBD and IBD in remission. It was able to verify early response of TNF-alpha therapy. Mucosal versus submucosal thickness was able to differentiate between UC and CD. Therefore, EUS of the colonic wall might be an important tool in diagnosis and management of patients with acute IBD. Further studies are needed to prove these limited data.
Tu1554 Direct Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis: A Meta-Analysis Nitin Kumar*1, Darwin Conwell1,2, Christopher C. Thompson1,2 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Harvard Medical School, Boston, MA Background: Direct Endoscopic Necrosectomy (DEN) is an endoscopic technique with an emerging role in the management of selected cases of walled-off pancreatic necrosis (WOPN). Aim: To evaluate the medical literature to determine the rate of nonsurgical resolution of endoscopically accessible WOPN after completed DEN. Methods: A comprehensive search of PubMed, OVID, and Embase including all dates until October 2011 was conducted. Outcomes of interest included time to necrosectomy, number of DEN needed, resolution of WOPN, and complication rate. Only studies in which patients underwent DEN as primary therapy for WOPN were included. Reports containing ⱕ5 patients of interest and studies containing patients included in subsequent reports were excluded. Working independently and in duplicate, two reviewers screened all abstracts and full text of eligible references and abstracted pertinent data. The results were combined using a fixed-effects model in Comprehensive Meta-analysis (Biostat, Englewood, NJ). Heterogeneity was assessed with Cochran’s Q and the I2 statistic. Publication bias was assessed with Begg-Mazumdar rank correlation. Results: 9 studies met inclusion criteria and contained 276 patients of interest. Cochran’s Q for heterogeneity yielded p-value of 0.325 and I2 was 13.2, suggesting that the studies can be combined. The fixed and random-effects models provided similar results. Begg-Mazumdar rank correlation Kendall’s tau was 0.06 (p⫽0.42) and Egger’s p⫽0.07, suggesting limited publication bias. Weighted mean time to necrosectomy after onset of symptoms was 7.5 weeks (95% CI 7.24-7.77). Weighted mean maximal diameter of the necrotic cavity was 13.0 cm (95% CI 12.8-13.3). Weighted mean number of procedures needed for resolution was 4.0 (95% CI 3.72-4.26). Pooled proportion for resolution after DEN was 85.7% (95% CI 80.8-89.5%). Forest plot for individual study proportions for resolution is shown in Figure 1. DEN-related complications, including bleeding, cyst perforation, and sepsis, were noted in 21.9% of patients (95% CI 20.5-23.4). Conclusions: This meta-analysis suggests that DEN is effective for the treatment of WOPN, with a high rate of clinical resolution and an acceptable safety profile.
AB444 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
Tu1548 Metallic Stent Deployment in Endosonography-Guided Biliary Drainage: Long Term Follow-up Results in Patients With BilioEnteric Anastomosis Jun Horaguchi*, Naotaka Fujita, Yutaka Noda, Go Kobayashi, Kei Ito, Shinsuke Koshita, Yoshihide Kanno, Takahisa Ogawa, Kaori Masu Sendai City Medical Center, Sendai, Japan Background: Though reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few case series have been reported on deployment of a self-expandable metal stent (SEMS) and its long-term results. Aim: To evaluate the safety and efficacy of SEMS deployment in ESBD. Patients and Methods: Of 40 patients who underwent ESBD due to difficult biliary cannulation in ERCP during the period from January 2007 to May 2011 in our department, 20 patients with unresectable malignant biliary obstruction in whom ESBD with a SEMS had been attempted were included. The male to female ratio was 9:11 and their average age was 73 years old. Puncture of the bile duct was performed with a 19G needle under endosonographic guidance. After dilation of the puncture tract, a plastic stent or SEMS was placed to bridge the intra-/ extrahepatic bile duct and the gastrointestinal tract. SEMS was deployed in the first session with the one-step technique or in the second session with replacement of a plastic stent with a SEMS. The technical success, early and late complications related to SEMS deployment, and stent patency of SEMS were evaluated. Results: One-step SEMS deployment was attempted in 6 patients, and SEMS deployment with stent exchange in 14, all of which were successful. In all patients who had undergone deployment of a SEMS with the one-step technique, the SEMS was deployed to the extrahepatic bile duct via the duodenum. In 9 of the 14 patients who had undergone stent exchange, the SEMS was deployed in the intrahepatic bile duct in 3 and in the extrahepatic bile duct in 6 in a bilioenteric anastomosis fashion. The other 5 patients who had initial plastic stent deployment in the intrahepatic bile duct underwent stent exchange for SEMS with antegrade deployment across the biliary stenosis. No complications relevant to the procedures were encountered in all patients. Late complications occurred in 3 of 15 patients who underwent deployment of SEMS in a bilio-enteric anastomosis fashion (stent obstruction in 2 and reflux cholangitis in 1). The mean survival and the mean stent patency period were 266 days and 279 days, respectively. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, SEMS can be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.
Tu1549 Practice Patterns in FNA Technique by U.S. Endosonographers: A Survey Analysis Christopher J. Dimaio*1, Seth A. Gross2, Jonathan Buscaglia3, ADAM J. Goodman4, Michelle K. Kim1, Shireen A. Pais5, Uzma D. Siddiqui6, Harry R. Aslanian6, Felice Schnoll-Sussman7, Sammy Ho8, Amrita Sethi9, David H. Robbins10, Satish Nagula3 1 Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY; 2Section of Gastroenterology, Norwalk Hospital, Norwalk, CT; 3 Division of Gastroenterology and Hepatology, Stony Brook University Medical Center, Stony Brook, NY; 4Division of Gastroenterology and Hepatology, SUNY Downstate Medical Center, Brooklyn, NY; 5 Gastroenterology & Hepatobiliary Diseases, New York Medical College, Valhalla, NY; 6Section of Digestive Diseases, Yale School of Medicine, New Haven, CT; 7Division of Gastroenterology & Hepatology, NewYorkPresbyterian Hospital/Weill Cornell Medical Center, New York, NY; 8 Gastroenterology & Liver Diseases, Montefiore Medical Center, Bronx, NY; 9Division of Digestive and Liver Diseases, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY; 10 Division of Gastroenterology, Lenox Hill Hospital, New York, NY Background: EUS-FNA has become a mainstay in the evaluation of various GI diseases. Despite its widespread use, little is known about the preferred FNA techniques used by practitioners. Aims: To ascertain FNA techniques by endosonographers with varying levels of experience and practice environments. Methods: GI physicians performing EUS-FNA in the U.S. were identified from a list of providers assembled by a major FNA needle manufacturer. E-mail addresses were queried via AGA, ASGE, & ACG membership directories. Subjects were e-mailed and asked to complete an anonymous electronic survey assessing their FNA practices. Results: A total of 681 practitioners were contacted; 216 (32%) completed the survey. Majority of respondents (54%) had completed a 4th year fellowship in EUS. Nearly half (48%) identified themselves as academic/ university-based practitioners, while 45% were community-based. All age ranges were equally represented. High-volume FNA (⬎150/year) was noted in 35% respondents, medium-volume FNA (75-150/year) in 37%, and low-volume FNA (⬍75/year) in 28%. The 22 gauge needle was the preferred needle size for initial FNA of solid pancreatic mass (63%), submucosal mass (72%) and lymph nodes (51%), with either 10-20 (50%) or 6-10 (37%) needle throws per pass. Most respondents used a stylet on the initial pass (92%) and on subsequent passes
www.giejournal.org
(83%). Suction was routinely used for solid lesions (86%) and less often for lymph nodes (67%). Rapid on-site evaluation of cytology (ROSE) was used by 76% of respondents. If ROSE is unavailable, 69% perform 3-5 needle passes. If inadequate specimen determined by ROSE, 42% cease and await results of cell block, while 23% changed to a core biopsy needle. If bloody specimen, 48% repeat FNA but without suction, while 24% repeat FNA with no changes. If final cytology non-diagnostic, 54% repeat EUS-FNA and consider using a core needle; 17% repeat EUS-FNA alone; 9% refer for percutaneous biopsy; 4% refer for surgical biopsy. If adequate tissue is not obtained via ROSE, low-volume EUS physicians (⬍150/year) were more likely to await results of cell-block compared to high-volume (43.1% vs. 29.3%), and high-volume EUS physicians were more likely to use a core needle (21.3% vs. 2.0%) (p ⫽ 0.024). If final cytology is nondiagnostic, high-volume EUS physicians were more likely than low volume physicians to repeat FNA with a core needle (60% vs. 31%), and low volume physicians were more likely to refer for either surgical or percutaneous biopsy, (33% vs. 5%) (p ⬍ 0.0001). Academic physicians were more likely to repeat FNA with a core needle (67%) compared to community physicians (39%, p ⬍ 0.001). Conclusions: There is moderate variation in EUS-FNA practices among EUS practitioners. Significant differences appear to be related to EUS volume & procedural environment.
Tu1550 Usefulness of EUS-FNA for GI Tract Lesions Ryoji Miyahara*1, Kohei Funasaka2, Kazuhiro Furukawa2, Keiichi Sakamaki2, Hidezumi Tatematsu2, Issei Tsurudome2, Fumiko Yamamoto2, Ippei Matsuzaki2, Eizaburo Ohno1, Hiroki Kawashima2, Akihiro Itoh2, Naoki Ohmiya2, Yoshiki Hirooka1, Osamu Watanabe2, Osamu Maeda2, Takafumi Ando2, Hidemi Goto2,1 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology, Nagoya University, graduate school of medicine, Nagoya, Japan Background and Study Design: To obtain accurate histopathological diagnosis of submucosal tumors (SMTs), EUS-FNA may be most suitable procedure. However, reports which examined usefulness and safety of EUS-FNA for GI tract lesions are still limited. In this study, we evaluated the usefulness of EUS-FNA for GI tract lesions from our experience. Patients and Methods: In our institution, we perform EUS-FNA for SMTs and lymph nodes which exist close to GI tarct to obtain accurate histopathological diagnosis for determining therapeutic strategy. We evaluated consecutive 258 cases from August 1994 to March 2011 retrospectively, involving 27 esophagus SMTs, 38 lymph nodes, 162 gastric SMTs, 11 duodenum SMTs, 18 colonic SMTs. Results: 1. A total of 258 patients underwent EUS-FNA(range 2-6 passes). We could obtain enough tissue in 88.8% of cases. Cases of inadequate specimens showed calcification and relatively small diameter (average; 14.6mm) in EUS images. 2. Pathological diagnosis of EUS-FNA were 11 leiomyoma and 4 GISTs in esophagus, 44 leiomyomas, 92 GISTs in stomach, 9 adenocarcinomas and 1 GIST in colon, 31 carcinomas and 5 infections in lymph nodes and othres. Compared diagnosis of EUS-FNA with those of surgical operation, the rate of accurate diagnosis of EUS-FNA was 93.3% in 90 cases which we performed both EUS-FNA and operation. 3. The rate of tissue sampling and accurate diagnosis were 81.4% and 100% in esophagus, 91.4% and 88.8% in stomach, 88.9% and 100% in colon, 86.8% and 100% in lymph node, respectively. 4. Only one patient had local peritonitis without seeding after EUS-FNA. 5. In 38 cases of GISTs, we stained tissues from EUS-FNA and surgical operation immunohistochemically with Ki-67 to determine the degree of malignancy. The accuracy of diagnosis of EUS-FNA was 81.6% in Ki-67 LI. Conclusion: We could obtain accurate diagnosis for SMTs and swelling lymph nodes in safety using EUS-FNA procedure.
Tu1551 Accuracy of Endoscopic Ultrasonography in Preoperative T Staging of an Early Gastric Cancer Denis Gusev*, Alexey A. Gvozdev, Sergey V. Kashin Yaroslavl regional cancer hospital, Yaroslavl, Russian Federation Background: Development of the advanced endoscopic therapeutic methods (EMR and ESD) of an early gastric cancer (EGC) treatment has increased the role of the endoscopic ultrasonography (EUS). EUS procedure has been providing in the Endoscopy dept. of Yaroslavl regional cancer hospital since 2006. Aim: To evaluate the diagnostic accuracy of EUS in the preoperative T staging of early gastric cancer. Methods: Sixty-seven patients with verified EGC (42M/25F, age: 47-87, mean age 67,9) were underwent esophagogastroduodenoscopy and probe EUS between 2006-2010. According to the PEC (2002) type 0-Ips was detected in 13,4% (9), type 0-IIa - 25,4% (17), type 0-IIa/c - 49,2% (33), type 0-IIb - 0, type 0-IIc - 6% (4), type 0-IIc/IIa - 6% (4). Olympus EU-M60 echo video system with MAJ-935 ultrasound probe imaging linear scanning transducer (20 MHz) were employed. EUS staging procedures for EGC depth of invasion (T stage) were performed according to the nine-layer structure of the gastric wall (1). EUS image of the fifth echo-layer of the gastric wall (submucosal) was accessed by
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB443
Abstracts
following criteria: 1) no changes, 2) unclear, 3) multiple echo-free spots, 4) budding sign, 5) irregular narrowing (2). 88% (n⫽58) patients underwent endoscopic treatment and 12% (n⫽9) patients - surgery. Diagnostic accuracy of EUS for T staging of the EGC was determined by comparing preoperative EUS with subsequent postoperative histopathology findings. Results: Depending on the growth of EGC within the mucosal layer diagnostic accuracy of EUS was 93%, within submucosal layer - 66%, within muscular layer - 66%. The overall diagnostic accuracy of EUS in preoperative determination of EGC depth of invasion was 75%. Depending on the type of the EGC accuracy of EUS was varying: type 0-Ips - 78%, type 0-IIa - 87,5%, type 0-IIa/c - 78%, type 0-IIb - 0, type 0-IIc - 75%, type 0-IIc/IIa - 75%. Predominant location and distribution of the EGC in the stomach were in the antrum - 50%, corpus (lower part - 16,5%, middle part - 9%, upper part - 9%), angle of stomach - 10,6%, cardia - 5%. The rates for overstaging and understaging were 20% and 5%, respectively. Conclusion: EUS is a useful diagnostic method for preoperative staging of EGC for T criteria. However, EUS tended to overstage T criteria, and misdiagnosis increases with depth of tumor invasion. The least accurate EUS was at type 0-IIc and type 0-IIc/IIa. The main reasons of misdiagnosis were biopsy effect, wrong interpretation of the submucosal layer, peristaltic movements and perifocal inflammatory changes.
Tu1552 Comparative Study of Sample Adequacy of 25G vs. 22G Needle in Endoscopic Ultrasound (EUS) Guided Fine Needle Aspirate (FNA) of Solid Lesions Aravinth U. Murugananthan*, Thai P. Hong, Robert Chen Gastroenterology, Western Health, Melbourne, VIC, Australia Background: Optimal needle size in achieving greatest diagnostic yield from EUS- guided FNA remains unclear. Aim: We prospectively compared sample adequacy and safety of FNA of solid lesions between 25G and 22G needle at two tertiary centres. Method: Prospective data from two sites was collected between November 2008 and November 2011. A single operator alternated on a case-by-case basis between a 25G and 22G needle. A cytopathologist was present to assess adequacy of sample. The operator could switch needle size if required. Results: 152 patients undergoing 165 FNA were analysed (42m/30f, mean age 59). 76 patients had FNA with a 22 F needle and 76 with the 25F needle. Indications for EUS and FNA were pancreatic lesions 43%, lymph node enlargement 28%, biliary tract lesions 16%, submucosal lesion 8% and adrenal mass 1% and others 4%. Overall sample adequacy was 83.03% Adequacy per needle was 86.7% (22G) vs. 79.2% (25G), p⫽0.22 Fischer’s Exact test. The number of passes used in successful FNA was higher with use of the 25G needle compared with the 22G needle. (2.42 0.11 SEM vs. 1.962 0.15 SEM, p⫽0.015, ttest). In particular the use of a 25G needle had a higher number of passes in pancreatic lesions compared with the 22G needle (2.580.16 SEM vs. 1.940.14, p⫽0.004, t-test).There was no difference in adequacy between the needle sizes for each type of lesion sampled (Table 1). Two needle exchanges (25G to a 22G) occurred. One complication of local site bleeding occurred (22G) that settled during the test. Conclusion: We show no difference in sample adequacy between the two needle sizes. Use of a 25G results is associated with a higher number of passes in pancreatic FNA. Both needle sizes appear safe/ Operator choice and ease of passage of needle into anatomical location may also have influence choice of needle. Table 1. Sample adequacy per site of lesion
Lesion Site Lymph node Biliary tract lesion Pancreatic lesion Submucosal Lesion
22G 25G Adequate Inadequate Adequate Inadequate Fischer’s Sample Sample Sample Sample Exact Test 19 9 33 4
4 2 3 2
20 11 33 2
3 4 2 5
NS NS NS NS
Tu1553 Endoscopic Ultrasound of the Colon Can Differentiate Between Crohn‘S Disease and Ulcerative Colitis and Reliably Quantifies the Degree of Inflammation - a Prospective, Blinded, and Controlled Comparative Study Mark Ellrichmann*1, Johannes Bethge1, Susanna Nikolaus1, Alexander Arlt1, Tanja Kuehbacher1, Stefan Schreiber1, Perdita Wietzke-Braun1, Wolfram Klapper2, Annette Fritscher-Ravens1 1 Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany; 2Department of Pathology, Universityhospital Schleswig-Holstein, Campus Kiel, Kiel, Germany Introduction: The prognosis of acute IBD is dependent on the severity of
inflammatory changes. To date this is evaluated by clinical criteria and endoscopic IBD scores, which do not assess changes of the entire gastrointestinal(GI)-wall. Recent developments in EUS might now allow objective differentiation between ulcerative colitis (UC) and Crohn‘s disease (CD) and quantification of the grade of inflammation which would provide a more precise measure of disease state and help judge success of treatment. Aim:To study prospectively the GI-wall and it’s layers with EUS in a blind, controlled, comparative manner for possible differentiation between UC/CD and quantification of the degree of inflammation. Methods: After IRB approval consecutive patients with either active/inactive CD, UC or healthy controls (HC) were examined using a forward-viewing radial echoendoscope. Mucosal(M), submucosal(SM) and total wall-thickness (TWT) were investigated by EUS in the mid sigmoid colon. A second examiner, blinded to the result of the colonoscopy, categorized the disease seen on EUS. EUS results were compared to macroscopic IBD scores (Baron-score for UC; SES-CD-score for CD). Histological inflammation scores served as gold standard. Results: In 61 HC there was clear differentiation of the different layers of the GI wall and a TWT(1.71⫾0.02mm) that was significantly thinner than in patients with acute IBD (n⫽52; TWT 3.51⫾0.15mm; p⬍0.001); no significant difference between UC/CD (p⫽0.06). In patients with acute UC significant thickening of the mucosa was observed but nearly normal SM. In acute CD significant thickening of the submucosal layer was seen with nearly normal M (MUC⫽2.08⫾0.11mm vs. MCD⫽1.32⫾0.17mm, p⫽0.0001; SMUC⫽1.01⫾0.08mm vs. SMCD⫽2.01⫾0.22mm, p⫽0.0001). In patients with UC Baron score and in CD SES-CD score TWT correlated in a highly significant manner (r⫽0.65; p⬍0.001 and r⫽0.76 ; p⬍0.001, respectively). In UC there was a significant correlation between TWT, histological activity scores (p⬍0.006) and the grade of inflammation (p⬍0.02). In CD there was a significant correlation between activity scores, grade of inflammation and TWT on EUS (p⬍0.001). Two patients with UC were re-examined 7 days after first dose of a TNF-alpha antagonist. Colonoscopy showed no macroscopic changes compared to the examination prior to therapy. On EUS mean TWT was reduced to 2.3mm, indicating a marked response to therapy. Discussion: EUS measurement of TWT was highly predictive of the level of inflammation in patients with acute IBD and IBD in remission. It was able to verify early response of TNF-alpha therapy. Mucosal versus submucosal thickness was able to differentiate between UC and CD. Therefore, EUS of the colonic wall might be an important tool in diagnosis and management of patients with acute IBD. Further studies are needed to prove these limited data.
Tu1554 Direct Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis: A Meta-Analysis Nitin Kumar*1, Darwin Conwell1,2, Christopher C. Thompson1,2 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Harvard Medical School, Boston, MA Background: Direct Endoscopic Necrosectomy (DEN) is an endoscopic technique with an emerging role in the management of selected cases of walled-off pancreatic necrosis (WOPN). Aim: To evaluate the medical literature to determine the rate of nonsurgical resolution of endoscopically accessible WOPN after completed DEN. Methods: A comprehensive search of PubMed, OVID, and Embase including all dates until October 2011 was conducted. Outcomes of interest included time to necrosectomy, number of DEN needed, resolution of WOPN, and complication rate. Only studies in which patients underwent DEN as primary therapy for WOPN were included. Reports containing ⱕ5 patients of interest and studies containing patients included in subsequent reports were excluded. Working independently and in duplicate, two reviewers screened all abstracts and full text of eligible references and abstracted pertinent data. The results were combined using a fixed-effects model in Comprehensive Meta-analysis (Biostat, Englewood, NJ). Heterogeneity was assessed with Cochran’s Q and the I2 statistic. Publication bias was assessed with Begg-Mazumdar rank correlation. Results: 9 studies met inclusion criteria and contained 276 patients of interest. Cochran’s Q for heterogeneity yielded p-value of 0.325 and I2 was 13.2, suggesting that the studies can be combined. The fixed and random-effects models provided similar results. Begg-Mazumdar rank correlation Kendall’s tau was 0.06 (p⫽0.42) and Egger’s p⫽0.07, suggesting limited publication bias. Weighted mean time to necrosectomy after onset of symptoms was 7.5 weeks (95% CI 7.24-7.77). Weighted mean maximal diameter of the necrotic cavity was 13.0 cm (95% CI 12.8-13.3). Weighted mean number of procedures needed for resolution was 4.0 (95% CI 3.72-4.26). Pooled proportion for resolution after DEN was 85.7% (95% CI 80.8-89.5%). Forest plot for individual study proportions for resolution is shown in Figure 1. DEN-related complications, including bleeding, cyst perforation, and sepsis, were noted in 21.9% of patients (95% CI 20.5-23.4). Conclusions: This meta-analysis suggests that DEN is effective for the treatment of WOPN, with a high rate of clinical resolution and an acceptable safety profile.
AB444 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org