- Email: [email protected]
⁎4556 Impact of biliary endoprostheses on endosonographic bile duct morphology in obstructive jaundice.
*4556 IMPACT OF BILIARY ENDOPROSTHESES ON ENDOSONOGRAPHIC BILE DUCT MORPHOLOGY IN OBSTRUCTIVE JAUNDICE. Andrew S. Crawford, Richard A. Erickson, Scott & White, Texas A&M Health Sci Ctr, Temple, TX. BACKGROUND: Some surgeons argue against preoperative stents for obstructive jaundice based on stent-induced inflammatory changes seen on biliary histology (Surgery 1992;111:562, J Am Coll Surg 1994;178:343). The purpose of this study was to test whether and how frequently endosonography (EUS) could demonstrate any changes in biliary morphology with the use of endoscopic biliary stents for obstructive jaundice. METHODS: Data were included from all patients undergoing upper EUS from 4/95 to 11/99 having non-stone associated obstructive jaundice from a distal common bile duct (CBD) lesion with no clinical evidence of cholangitis. Patients were divided into two groups, those having an EUS before any endoscopic stent was placed and those having EUS after a plastic stent had been placed for obstructive jaundice. Patient demographics, average CBD diameter and width and the presence of biliary sludge were ascertained in both groups. RESULTS: A total of 87 patients were studied (see table) with 22 patients in the stented group. Endoprostheses were in place for an average of 3 weeks at the time of EUS. There were no significant differences in the age or sex distribution, but malignant obstruction was more frequent in the non-stented group. Patients with stents had smaller duct diameters; however, the average duct wall thickness was almost twice that seen in non-stented ducts. Stented patients had CBD sludge more frequently. CONCLUSION: Confirming previous pathologic reports, this study demonstrates that endosonographically evident duct wall thickening and CBD sludge is indeed a frequent finding after stent placement for obstructive jaundice. Whether these changes contribute to the poorer surgical outcomes reported by some groups with preoperative stenting (Arch Surg 1998;133:149)is still unclear.
Stented (22) CBD diameter (cm) CBD width (mm) % with CBD sludge % with malignant obsstruction
0.87 ± 0.12 (SEM) 2.75 ± 0.18 73% 64%
No Stent (65) 1.60 ± 0.05 1.45 ± 0.06 42% 94%
p<0.001 p<0.001 p<0.01 p<0.005
*4557 USEFULNESS OF ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION BIOPSY IN THE DIAGNOSIS OF NEUROENDOCRINE TUMORS NOT VISUALIZED BY OTHER IMAGING MODALITIES. A. Gines, E. Vazquez-Sequeiros, I. D. Norton, J. E. Clain, K. K. Wang, M. J. Wiersema, Mayo Clin, Rochester, MN. Background: Suspicion of neuroendocrine tumors is often based on clinical symptoms and hormonal tests. To define the location of these tumors is difficult due to their small size at the time of diagnosis. EUS has been proven to be the most accurate method for diagnosis of small pancreatic tumors and small lesions of the duodenum wall. Nevertheless, to date, the role of EUS-FNA cytology for neuroendocrine tumor diagnosis has not been defined. Aim: Determine the utility of EUS-FNA in the diagnosis of small functioning neuroendocrine tumors not detected by other imaging modalities. Patients and Methods: From 1993 to 1999, 9 patients with clinical suspicion for neuroendocrine tumor underwent EUS-FNA to determine location and allow cytologic confirmation of the tumor. Mean age was 52 years (range 35-69) and male/female ratio was 4/5. Four patients presented with hypoglycemia, 2 with diarrhea and the remaining three had been diagnosed with Zollinger-Ellison syndrome. Three of these patients had a previously known MEN I syndrome. All patients had hormonal disturbances that strongly suggested the presence of a neuroendocrine tumor. EUS was routinely performed under conscious sedation with the mechanical radial instrument (Olympus GFUM 20 or GFUM 130) and, when the lesion was identified, FNA was performed under guidance with the curved linear array (Olympus GFUM 30P or Pentax FG 32UA). Results: EUS was able to visualize 13 tumors in these 9 patients (two out of three patients with known MEN I syndrome had two and four lesions respectively). In all but one patient CT did not show the tumor or missed at least one of the lesions. Two patients had exploratory surgery with intraoperative ultrasound prior to referral to our institution that failed to identify the tumor. Mean tumor size was 12 mm (range 4-25) and the tumor location was pancreas (n=12) or duodenal wall (n=1). EUS-FNA was performed in 11 of the
VOLUME 51, NO. 4, PART 2, 2000
13 lesions detected. EUS-FNA accurately diagnosed neuroendocrine tumor in all cases. Seven patients underwent surgical resection confirming EUSFNA findings in all of them (accuracy 100%). No complications were observed. Conclusions: EUS is a highly accurate technique to visualize small size neuroendocrine tumors of those not seen on CT, this is specially important in those patients with multiple lesions. EUS-FNA safely provides cytologic confirmation with a high accuracy in these patients. *4558 PRELIMINARY RESULTS OF EUS GUIDED FINE-NEEDLE ASPIRATION CYTODIAGNOSIS OF HILAR CHOLANGIOCARCINOMA. Annette Fritscher-Ravens, Parupudi V. Sriram, Theodoros Topalidis, Stefan Jaeckle, Frank Thonke, Dieter C. Broering, Nib Soehendra, Dept of Interdisciplinary Endoscopy, Hamburg, Germany; Institute Atay /Topalidis, Hannover, Germany; Dept of Hepatobiliary Surg, Hamburg, Germany. Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks. *4559 LONG TERM FOLLOW-UP OF EARLY CHRONIC PANCREATITIS DIAGNOSED AT ENDOSCOPIC ULTRASONOGRAPHY. Laurent Heyries, Marc A. Barthet, Louis Buscail, Philippe Pages, Jean Escourrou, Jose Sahel, Hosp Sainte Marguerite, Marseille, France; INSERM U 315, Marseille, France; CHU Rangueil, Toulouse, France; Hosp Rangueil, Toulouse, France. Aim : The diagnosis of early chronic pancreatitis (ECP) remains difficult and endoscopic ultrasonography (EUS) features are still controversial. The aim of this study was to evaluate the long term follow-up of patients with ECP diagnosed at EUS. Methods : Between 1994 and 1998, 37 patients were diagnosed to have ECP at EUS. All experienced at least one episode of non biliary acute pancreatitis. None had evidence of pancreatic stone on plain film of the abdomen or on CTscanner. The ECP were classified as group A (possible ECP with either parenchymal signs or ductal signs), as group B (probable ECP with both parenchymal and ductal signs) and as group C (certain ECP with pancreatic stones). Results : 11 patients were lost to follow-up, 26 men with median age of 46.5 (23-70) years and median alcohol consumption of 76 ( 0-150) g per day, have been followed for a median duration of 37 (1-94).months. - At the initial examination, 10 patients belonged to group A, 4 to group B and 12 to group C. The pancreatographies (n=24) according to the Cambridge classification were 7 cases in stage 0, 4 cases in stage 1 , 4 cases in stage 2 and 9 cases in stage 3. - At the end of the follow-up, 4 patients underwent surgery (pseudotumorous chronic pancreatitis in 2 cases, duodenal cystic dystrophy in 1 case, and pancreatic cancer complicating chronic pancreatitis in 1 case). 26 patients had clinical evaluation : 12 remained unchanged, 12 had improved health status and 2 still experienced clinical disorders (pain, weight-loss). The final diagnosis of certain ECP was yeldied in 6 out of 10 patients of the group A, in 3 out of 4 patients of the group B and in 9 out of the 12 patients of the group C. Conclusion : The positive predictive value of EUS signs of ECP was 64% in case of possible or probable ECP and 75% in case of certain ECP.
GASTROINTESTINAL ENDOSCOPY
AB167
Stented (22) CBD diameter (cm) CBD width (mm) % with CBD sludge % with malignant obsstruction
0.87 ± 0.12 (SEM) 2.75 ± 0.18 73% 64%
No Stent (65) 1.60 ± 0.05 1.45 ± 0.06 42% 94%
p<0.001 p<0.001 p<0.01 p<0.005
*4557 USEFULNESS OF ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION BIOPSY IN THE DIAGNOSIS OF NEUROENDOCRINE TUMORS NOT VISUALIZED BY OTHER IMAGING MODALITIES. A. Gines, E. Vazquez-Sequeiros, I. D. Norton, J. E. Clain, K. K. Wang, M. J. Wiersema, Mayo Clin, Rochester, MN. Background: Suspicion of neuroendocrine tumors is often based on clinical symptoms and hormonal tests. To define the location of these tumors is difficult due to their small size at the time of diagnosis. EUS has been proven to be the most accurate method for diagnosis of small pancreatic tumors and small lesions of the duodenum wall. Nevertheless, to date, the role of EUS-FNA cytology for neuroendocrine tumor diagnosis has not been defined. Aim: Determine the utility of EUS-FNA in the diagnosis of small functioning neuroendocrine tumors not detected by other imaging modalities. Patients and Methods: From 1993 to 1999, 9 patients with clinical suspicion for neuroendocrine tumor underwent EUS-FNA to determine location and allow cytologic confirmation of the tumor. Mean age was 52 years (range 35-69) and male/female ratio was 4/5. Four patients presented with hypoglycemia, 2 with diarrhea and the remaining three had been diagnosed with Zollinger-Ellison syndrome. Three of these patients had a previously known MEN I syndrome. All patients had hormonal disturbances that strongly suggested the presence of a neuroendocrine tumor. EUS was routinely performed under conscious sedation with the mechanical radial instrument (Olympus GFUM 20 or GFUM 130) and, when the lesion was identified, FNA was performed under guidance with the curved linear array (Olympus GFUM 30P or Pentax FG 32UA). Results: EUS was able to visualize 13 tumors in these 9 patients (two out of three patients with known MEN I syndrome had two and four lesions respectively). In all but one patient CT did not show the tumor or missed at least one of the lesions. Two patients had exploratory surgery with intraoperative ultrasound prior to referral to our institution that failed to identify the tumor. Mean tumor size was 12 mm (range 4-25) and the tumor location was pancreas (n=12) or duodenal wall (n=1). EUS-FNA was performed in 11 of the
VOLUME 51, NO. 4, PART 2, 2000
13 lesions detected. EUS-FNA accurately diagnosed neuroendocrine tumor in all cases. Seven patients underwent surgical resection confirming EUSFNA findings in all of them (accuracy 100%). No complications were observed. Conclusions: EUS is a highly accurate technique to visualize small size neuroendocrine tumors of those not seen on CT, this is specially important in those patients with multiple lesions. EUS-FNA safely provides cytologic confirmation with a high accuracy in these patients. *4558 PRELIMINARY RESULTS OF EUS GUIDED FINE-NEEDLE ASPIRATION CYTODIAGNOSIS OF HILAR CHOLANGIOCARCINOMA. Annette Fritscher-Ravens, Parupudi V. Sriram, Theodoros Topalidis, Stefan Jaeckle, Frank Thonke, Dieter C. Broering, Nib Soehendra, Dept of Interdisciplinary Endoscopy, Hamburg, Germany; Institute Atay /Topalidis, Hannover, Germany; Dept of Hepatobiliary Surg, Hamburg, Germany. Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks. *4559 LONG TERM FOLLOW-UP OF EARLY CHRONIC PANCREATITIS DIAGNOSED AT ENDOSCOPIC ULTRASONOGRAPHY. Laurent Heyries, Marc A. Barthet, Louis Buscail, Philippe Pages, Jean Escourrou, Jose Sahel, Hosp Sainte Marguerite, Marseille, France; INSERM U 315, Marseille, France; CHU Rangueil, Toulouse, France; Hosp Rangueil, Toulouse, France. Aim : The diagnosis of early chronic pancreatitis (ECP) remains difficult and endoscopic ultrasonography (EUS) features are still controversial. The aim of this study was to evaluate the long term follow-up of patients with ECP diagnosed at EUS. Methods : Between 1994 and 1998, 37 patients were diagnosed to have ECP at EUS. All experienced at least one episode of non biliary acute pancreatitis. None had evidence of pancreatic stone on plain film of the abdomen or on CTscanner. The ECP were classified as group A (possible ECP with either parenchymal signs or ductal signs), as group B (probable ECP with both parenchymal and ductal signs) and as group C (certain ECP with pancreatic stones). Results : 11 patients were lost to follow-up, 26 men with median age of 46.5 (23-70) years and median alcohol consumption of 76 ( 0-150) g per day, have been followed for a median duration of 37 (1-94).months. - At the initial examination, 10 patients belonged to group A, 4 to group B and 12 to group C. The pancreatographies (n=24) according to the Cambridge classification were 7 cases in stage 0, 4 cases in stage 1 , 4 cases in stage 2 and 9 cases in stage 3. - At the end of the follow-up, 4 patients underwent surgery (pseudotumorous chronic pancreatitis in 2 cases, duodenal cystic dystrophy in 1 case, and pancreatic cancer complicating chronic pancreatitis in 1 case). 26 patients had clinical evaluation : 12 remained unchanged, 12 had improved health status and 2 still experienced clinical disorders (pain, weight-loss). The final diagnosis of certain ECP was yeldied in 6 out of 10 patients of the group A, in 3 out of 4 patients of the group B and in 9 out of the 12 patients of the group C. Conclusion : The positive predictive value of EUS signs of ECP was 64% in case of possible or probable ECP and 75% in case of certain ECP.
GASTROINTESTINAL ENDOSCOPY
AB167