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Another caveat for endoscopic ultrasound–guided fine needle aspiration
Letters to the Editor
to objective, "high-yield" indications. 4 Some patient problems may be better suited to initial consultation. 4. Does performing open access endoscopy for "appropriate" indications actually improve patient care? We are in our infancy in regard to studying this issue. In a recent report, Zuccaro and Provencher6 found that specialists request EGD more frequently for appropriate indications compared with nonspecialists and have a higher yield of information relevant to patient care. Although the study had limitations, it represents at least a firstattempt in the United States to study outcomes in an open access endoscopic practice. Much more investigation is needed. 5. Who should be performing endoscopy? I raise this final point with trepidation, in part because it goes beyond the issue of open access endoscopy and appropriate indications for procedures. A large fraction of endoscopic procedures in the United States, particularly in rural areas and smaller communities, are being performed by primary care providers who have substantially less training in endoscopy and gastrointestinal disease than gastroenterologists. Although we assume that patients are best served when endoscopic services (be they open access or not) are provided by gastroenterologists, there is no proof that this is true. Further, some physicians have proposed that EGD and colonoscopy be performed by nonphysicians. It will be a challenge to find ways to study . these important issues. Although I believe that open access endoscopy can and does deliver medical care in a cost-efficient manner compared with the more traditional delivery system in the United States, this assertion remains to be shown, and improvements are needed. B. MARSHALL, MD Columbia, Missouri
JOHN
REFERENCES 1. Silcock JG, Bramble MG. Open access gastroscopy: second survey df current practice in the United States. Gut 1997;40:192-5. 2. Bramble MG. Open access endoscopy: a nationwide survey of current practice. Gut 1992;33:282-5. 3. Mahajan R.I, Marshall JB. Prevalence of open access gastrointestinal endoscopy in the United States. Gastrointest Endosc 1997;46:21-6. 4. ShaheenNJ, Bozymski EM. Open access endoscopy: cognition, technician, or some of both [editorial]? Gastrointest Endosc 1997;46:84-7. 5. Mahajan R.I, Barthel JS, Marshall JB. Appropriateness of referrals for open access endoscopy: how do physicians in different medical specialties do? Arch Intern Med 1996;156: 2065-9.
658 GASTROINTESTINAL ENDOSCOPY
6. Zuccaro G Jr, Provencher K. Does an open access system properly utilize endoscopic resources? Gastrointest Endosc 1997;46:15-20. 7. American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Manchester, Mass: American Society for Gastrointestinal Endoscopy; 1992. 8. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology 1998; 114:579-81. 9. AGA technical review : evaluation of dyspepsia. Gastroenterology 1998;114:582-95.
Another caveat for endoscopic ultrasound-guided fine needle aspiration To the editor: I read with great interest the editorial by Dr. Tiot on endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). I performed EUS-guided FNA on a patient with a pancreatic mass in the body-tail region with a cytopathologist present in the procedure room to examine the cytologic smears immediately after each pass. The pathologist indicated that there was good cellularity, that pancreatic cells were seen, and that the cells appeared to be normal without evidence of malignancy. The patient had no distant metastases. He had epigastric pain, weight loss , and no risk factors for pancreatitis. The mass appeared to be resectable at EUS examination, and thus the patient underwent surgical exploration with the potential for curative resection if pancreatic cancer was found_ During the operation when the abdominal cavity was entered, multiple, metastatic peritoneal nodules were seen. Frozen section examination of these nodules revealed adenocarcinoma suggestive of a pancreatic origin. The tumor was considered unresectable, and the abdomen was closed_The histologic sections from the peritoneal nodule and the cytologic slides from the EUS-guided FNA were compared, and the morphologic features of the cells were found to be very similar. The tumor was so well differentiated that in the needle aspirate, individual cells appeared similar to normal pancreatic cells. Thus it is important to remember that EUS-guided pancreatic FNA may be read as negative for carcinoma in the presence of an extremely well-differentiated malignant neoplasm. Manoop S. Bhutani, MD, FACP University of Florida Gainesville, Florida
REFERENCE 1. Tio TL. EUS guided FNA: a few caveats [editorial).
Gastrointest Endosc 1998;47:421-3.
VOLUME 48, NO.6, 1998
to objective, "high-yield" indications. 4 Some patient problems may be better suited to initial consultation. 4. Does performing open access endoscopy for "appropriate" indications actually improve patient care? We are in our infancy in regard to studying this issue. In a recent report, Zuccaro and Provencher6 found that specialists request EGD more frequently for appropriate indications compared with nonspecialists and have a higher yield of information relevant to patient care. Although the study had limitations, it represents at least a firstattempt in the United States to study outcomes in an open access endoscopic practice. Much more investigation is needed. 5. Who should be performing endoscopy? I raise this final point with trepidation, in part because it goes beyond the issue of open access endoscopy and appropriate indications for procedures. A large fraction of endoscopic procedures in the United States, particularly in rural areas and smaller communities, are being performed by primary care providers who have substantially less training in endoscopy and gastrointestinal disease than gastroenterologists. Although we assume that patients are best served when endoscopic services (be they open access or not) are provided by gastroenterologists, there is no proof that this is true. Further, some physicians have proposed that EGD and colonoscopy be performed by nonphysicians. It will be a challenge to find ways to study . these important issues. Although I believe that open access endoscopy can and does deliver medical care in a cost-efficient manner compared with the more traditional delivery system in the United States, this assertion remains to be shown, and improvements are needed. B. MARSHALL, MD Columbia, Missouri
JOHN
REFERENCES 1. Silcock JG, Bramble MG. Open access gastroscopy: second survey df current practice in the United States. Gut 1997;40:192-5. 2. Bramble MG. Open access endoscopy: a nationwide survey of current practice. Gut 1992;33:282-5. 3. Mahajan R.I, Marshall JB. Prevalence of open access gastrointestinal endoscopy in the United States. Gastrointest Endosc 1997;46:21-6. 4. ShaheenNJ, Bozymski EM. Open access endoscopy: cognition, technician, or some of both [editorial]? Gastrointest Endosc 1997;46:84-7. 5. Mahajan R.I, Barthel JS, Marshall JB. Appropriateness of referrals for open access endoscopy: how do physicians in different medical specialties do? Arch Intern Med 1996;156: 2065-9.
658 GASTROINTESTINAL ENDOSCOPY
6. Zuccaro G Jr, Provencher K. Does an open access system properly utilize endoscopic resources? Gastrointest Endosc 1997;46:15-20. 7. American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Manchester, Mass: American Society for Gastrointestinal Endoscopy; 1992. 8. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology 1998; 114:579-81. 9. AGA technical review : evaluation of dyspepsia. Gastroenterology 1998;114:582-95.
Another caveat for endoscopic ultrasound-guided fine needle aspiration To the editor: I read with great interest the editorial by Dr. Tiot on endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). I performed EUS-guided FNA on a patient with a pancreatic mass in the body-tail region with a cytopathologist present in the procedure room to examine the cytologic smears immediately after each pass. The pathologist indicated that there was good cellularity, that pancreatic cells were seen, and that the cells appeared to be normal without evidence of malignancy. The patient had no distant metastases. He had epigastric pain, weight loss , and no risk factors for pancreatitis. The mass appeared to be resectable at EUS examination, and thus the patient underwent surgical exploration with the potential for curative resection if pancreatic cancer was found_ During the operation when the abdominal cavity was entered, multiple, metastatic peritoneal nodules were seen. Frozen section examination of these nodules revealed adenocarcinoma suggestive of a pancreatic origin. The tumor was considered unresectable, and the abdomen was closed_The histologic sections from the peritoneal nodule and the cytologic slides from the EUS-guided FNA were compared, and the morphologic features of the cells were found to be very similar. The tumor was so well differentiated that in the needle aspirate, individual cells appeared similar to normal pancreatic cells. Thus it is important to remember that EUS-guided pancreatic FNA may be read as negative for carcinoma in the presence of an extremely well-differentiated malignant neoplasm. Manoop S. Bhutani, MD, FACP University of Florida Gainesville, Florida
REFERENCE 1. Tio TL. EUS guided FNA: a few caveats [editorial).
Gastrointest Endosc 1998;47:421-3.
VOLUME 48, NO.6, 1998