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Does Endoscopic Ultrasonography Influence the Management of Patients with Dilated Common Bile Duct?
Abstracts
W1321 Endoscopic Ultrasound (EUS)-Guided Angiography: a Novel Approach to Diagnostic and Therapeutic Intervention in the Vascular System Priscilla Magno, Samuel Giday, Jonathan Buscaglia, Clarke O. John, Chung-Wang Ko, Lori Wroblewski, Marcia I. Canto, Anthony N. Kalloo, Sergey V. Kantsevoy, Sanjay Jagannath
W1323 Endosonographically Guided Fine Needle Aspiration (EUS-FNA) of Solid Pancreatic Mass Lesions: Comparison of Histological and Cytological Analyses Kathleen Moeller, Thomas Toermer, Mario Sarbia, Hubert Martin, Ulrich Schenck, Hans-Joachim Schulz, Hans-Dieter Allescher, Alexander Meining, Harald Schmidt, Thomas Roesch
The ability to visualize and offer therapeutic intervention in the vascular tree makes interventional angiography an invaluable asset in patient care. Currently, all nonsurgical vascular intervention must be performed via a percutaneous route. Aim: To identify the technical challenges and to assess the feasibility of EUS-guided angiography in a porcine model. Methods: This study was approved by the Animal Institutional Review Board. Three 50-kg pigs were intubated and underwent general anesthesia. A linear EUS (OlympusÒ GF-UCT140) was performed with imaging performed at 16 mHz (Aloka Prosound SSD 5000). The thoracic and abdominal aorta, celiac axis, superior mesenteric artery, splenic vein, portal vein, splenic artery, and hepatic veins were all identified. Under EUS-guidance, vessels were systematically injected with iohexol contrast (350 mgI/mL, OminipaqueÔ) at an approximate rate of 1 mL/second. Angiography was performed using different gauge fine-needle aspirate (FNA) needles (OlympusÒ 19 g, 22 g and Wilson-CookÒ 25 g) with continuous fluoroscopic monitoring. Pigs were euthanized immediately after vascular injection for post-mortem examination. Results: There was excellent EUSvisualization of the abdominal aorta, celiac axis and splenic artery, splenic and portal vein in the porcine model. There were no technical difficulties in selectively injecting each vessel. None of the pigs suffered any acute hemodynamic compromise with EUS-guided vascular injection of any vessels. At necropsy, the 25 g FNA needle did not cause any visible vascular damage or bleeding. The 22 g needle showed a visible puncture site on the vessel without any active bleeding. In one pig, the 19 g needle caused a localized vascular hematoma around large caliber vessels, and approximately 150 mL of intra-abdominal blood. Injection of contrast was technically easiest with the 19 g FNA needle, and most difficult with the 25 g FNA needle. Injection of the aorta, celiac axis, and superior mesenteric artery demonstrated a blush of contrast. Selective injection of the splenic artery and hepatic artery demonstrated clear vascular opacification. Conclusions: This is the first study to define the technical challenges and feasibility of EUS-guided angiography. Vascular injection using a 25 g needle can be performed safely, but technical challenges remain to achieve a sufficient flow rate of contrast for adequate visualization of large vessels. The proximity of the intestinal wall to vasculature is favorable for an EUSguided approach. Currently, studies are being performed to improve vascular imaging, and evaluate feasibility of therapy with long-term survival.
Aim of the Study: To compare the diagnostic accuracy of histologicy and cytologicy from endosonographically guided fine needle aspiration specimens in patients with solid pancreatic tumours. Assessment of potential diagnostic gain by histology over cytology. Patients and Methods: 104 consecutive EUS-FNA were analysed retrospectively which were performed in two centers using the same methodological approach by two experienced examiners. EUS (Olympus GF UCT 140/160P; Pentax EG 3830 UT) and FNA (22-G-FNA; Wilson Cook, Mediglobe) were performed in standarde fashion; solid cylindric material gained by introducing the stylet into the needle was sent for histology, whereas the remaining fluid material was smeared for cytologic analysis. Results: Material suitable for cytological analysis was obtained in 96,1%, whereas this rate was only 74,6% for histology. Final diagnosis including independent tissue confirmation or follow-up was adenocarcinoma n Z 54; neuroendocrine tumour n Z 5; other malignant tumour n Z 8, inflammatory lesions n Z 37. Sensitivity and specificity for the diagnosis of malignancy were 74,6% and 94,7% (cytology) and 58,2% and 89,2% (histology). In the subgroup of adequate specimens sensitivities and specificities were similar (cytology 78,1% and 100%, histology 69,6% and 97,5%). The combination of both methods increased sensitivity to 85.2% (specificity 97,2%). A specific tumor tissue characterization was possible in 20-41% by cytology and 25-44% by histology depending on tumor type. Summary/Conclusions: Due to a higher percentage of insufficient material, sensitivity and specificity of EUS-FNA-histology in pancreatic tumors were lower than those of EUS-FNA-cytology. The combination of both techniques improved the overall results of EUS-FNA.
W1322 A Prospective Study of Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis Combined with Local Chemotherapy for Pancreatic Cancer Pain Yanqing Li, Ning Zhong, Wenjie Li, Hongbo Ren, Youan Zhao
W1324 Does Endoscopic Ultrasonography Influence the Management of Patients with Dilated Common Bile Duct? Shinji Okaniwa, Yoshiyuki Nakamura, Manabu Hiraguri, Naoto Horigome, Gengo Kaneko, Yuko Okaniwa, Nobuo Itoh
Objective: Since the general condition of patients in advanced stage pancreatic cancer is usually too poor to tolerate traditional intravenous chemotherapy, a EUS guide local chemotherapy was developed in order to get long-term control of abdominal pain. The aim of this study was to evaluate the long-term effect of EUSguided celiac plexus neurolysis combined with local chemotherapy on abdominal pain associated with pancreatic cancer. Methods: Twenty-three patients with painful and inoperable pancreatic cancer were evaluated at before and 20 weeks after EUS celiac plexus neurolysis combined with local chemotherapy. EUS CPN was performed with a linear array echoendoscope (Pentax EG3630U, Pentax Precision Instruments) Under direct EUS visualization, After injecting 2 mL of saline solution to clear the needle adjacent and anterior to the lateral aspect of the aorta at the level of the celiac trunk, 10 mL of dehydrated 98% absolute alcohol was injected. The process was then repeated on the opposite side of the aorta. EUS guide local chemotherapy was performed with the same echoendoscope and aspiration needle. Under direct EUS visualization, 1 mg/ml Cisplatin (DDP) solution was injected into tumor tissues directly. The total dose of DDP was about 15 mg for tumors which diameters were less than 40 millimeter, while for tumors larger than 40 millimeter, the total dose increased to 20 mg. Pain scores were assessed with a standardized 11-point continuous visual analog pain scale. Results: The study population consisted of 18 men and 5 women (mean age 57 years; range 48 to 67 years). Of the 23 patients enrolled, 7 had the tumor located in the head of the pancreas, 13 in the body or the tail, and 3 patients had diffuse pancreatic involvement. There were no major complications in both the EUS CPN and EUS guide local chemotherapy. Five patients had transient abdominal pain after the procedure, which persisted less than 48 hours and was relieved by an increase in the dosage of pain medication. 10 patients suffered with male nausea and vomiting after chemotherapy, no bone marrow depression was founded. Overall pain scores decreased significantly after EUS CPN combined with EUS guide local chemotherapy. There were no statistically significant changes of the diameters of the tumors before and after the treatment procedure. Conclusion EUS-guided celiac plexus neurolysis combined with local chemotherapy is effective and safe in long-term control of abdominal pain associated with pancreatic cancer. Potential benefits of this procedure require further investigation to identify advantages of this approach over conventional general intravenous chemotherapy.
Purpose: Precise evaluation of patients with dilated common bile duct (CBD) is extremely important. Computed tomography (CT) shows high sensitivity in detecting dilated CBD as well as the level of obstruction, and is usually used as the first modality. In some cases however, CT can not demonstrate the cause. This study is designed to evaluate the usefulness of endoscopic ultrasonography (EUS) in detecting the cause of CBD dilatation in patients in whom CT could not detect the cause or only revealed equivocal findings. Methods: In this study, we retrospectively analyzed 114 available cases with dilated CBD detected with CT (O9 mm in diameter) between April 2000 and August 2005. Final diagnoses were determined by endoscopic retrograde cholangiopancreatography and surgical exploration, and all cases diagnosed as only dilated CBD were followed up at least 6 months after diagnosed. As CBD stones and biliopancreatic carcinomas (BPC) are determinant factors for the management of patients with CBD dilatation, we evaluate the diagnostic accuracy in detecting these diseases in the following diagnostic processes. First, we evaluated these diseases solely using CT in all cases. When CBD stones were detected, we performed endoscopic treatment without EUS. Second, we performed EUS additionally for all cases and reconsidered the management of patients according to EUS findings. All cases were classified into 3 groups: dilated CBD only, with CBD stones, with BPC. Results: The number of each group was as follows: dilated CBD only, 20 (including post gastrectomy 2, post cholecystectomy 5); with CBD stones, 44; with BPC, 50 (gallbladder carcinoma 2, extra hepatic bile duct carcinoma 24, carcinoma of the ampulla of Vater 8 and pancreatic carcinoma 16). Solely using CT, 10 of 44 cases with CBD stones were misdiagnosed as dilated CBD only and 4 cases with BPC were missed (extra hepatic bile duct carcinoma 2 and ampullary carcinoma 2). So 14 cases were incorrectly diagnosed in total, and the over all accuracy was 87.7% (100/114). EUS was performed in 80 cases, and 10 cases with CBD stones and 4 cases with BPC were correctly diagnosed additionally. So, an additional EUS influenced all 14 misdiagnosed cases. Though CT could reveal equivocal findings in extra hepatic bile duct carcinomas, neither CT nor MRI could detect any findings except for CBD dilatation in non invasive minute ampullary carcinomas. Conclusions: EUS is very useful in detecting the CBD stones and BPC, particularly minute carcinoma of the ampulla of Vater. We recommend EUS in patients in whom CT could not detect any cause or only revealed equivocal findings.
www.giejournal.org
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB267
W1321 Endoscopic Ultrasound (EUS)-Guided Angiography: a Novel Approach to Diagnostic and Therapeutic Intervention in the Vascular System Priscilla Magno, Samuel Giday, Jonathan Buscaglia, Clarke O. John, Chung-Wang Ko, Lori Wroblewski, Marcia I. Canto, Anthony N. Kalloo, Sergey V. Kantsevoy, Sanjay Jagannath
W1323 Endosonographically Guided Fine Needle Aspiration (EUS-FNA) of Solid Pancreatic Mass Lesions: Comparison of Histological and Cytological Analyses Kathleen Moeller, Thomas Toermer, Mario Sarbia, Hubert Martin, Ulrich Schenck, Hans-Joachim Schulz, Hans-Dieter Allescher, Alexander Meining, Harald Schmidt, Thomas Roesch
The ability to visualize and offer therapeutic intervention in the vascular tree makes interventional angiography an invaluable asset in patient care. Currently, all nonsurgical vascular intervention must be performed via a percutaneous route. Aim: To identify the technical challenges and to assess the feasibility of EUS-guided angiography in a porcine model. Methods: This study was approved by the Animal Institutional Review Board. Three 50-kg pigs were intubated and underwent general anesthesia. A linear EUS (OlympusÒ GF-UCT140) was performed with imaging performed at 16 mHz (Aloka Prosound SSD 5000). The thoracic and abdominal aorta, celiac axis, superior mesenteric artery, splenic vein, portal vein, splenic artery, and hepatic veins were all identified. Under EUS-guidance, vessels were systematically injected with iohexol contrast (350 mgI/mL, OminipaqueÔ) at an approximate rate of 1 mL/second. Angiography was performed using different gauge fine-needle aspirate (FNA) needles (OlympusÒ 19 g, 22 g and Wilson-CookÒ 25 g) with continuous fluoroscopic monitoring. Pigs were euthanized immediately after vascular injection for post-mortem examination. Results: There was excellent EUSvisualization of the abdominal aorta, celiac axis and splenic artery, splenic and portal vein in the porcine model. There were no technical difficulties in selectively injecting each vessel. None of the pigs suffered any acute hemodynamic compromise with EUS-guided vascular injection of any vessels. At necropsy, the 25 g FNA needle did not cause any visible vascular damage or bleeding. The 22 g needle showed a visible puncture site on the vessel without any active bleeding. In one pig, the 19 g needle caused a localized vascular hematoma around large caliber vessels, and approximately 150 mL of intra-abdominal blood. Injection of contrast was technically easiest with the 19 g FNA needle, and most difficult with the 25 g FNA needle. Injection of the aorta, celiac axis, and superior mesenteric artery demonstrated a blush of contrast. Selective injection of the splenic artery and hepatic artery demonstrated clear vascular opacification. Conclusions: This is the first study to define the technical challenges and feasibility of EUS-guided angiography. Vascular injection using a 25 g needle can be performed safely, but technical challenges remain to achieve a sufficient flow rate of contrast for adequate visualization of large vessels. The proximity of the intestinal wall to vasculature is favorable for an EUSguided approach. Currently, studies are being performed to improve vascular imaging, and evaluate feasibility of therapy with long-term survival.
Aim of the Study: To compare the diagnostic accuracy of histologicy and cytologicy from endosonographically guided fine needle aspiration specimens in patients with solid pancreatic tumours. Assessment of potential diagnostic gain by histology over cytology. Patients and Methods: 104 consecutive EUS-FNA were analysed retrospectively which were performed in two centers using the same methodological approach by two experienced examiners. EUS (Olympus GF UCT 140/160P; Pentax EG 3830 UT) and FNA (22-G-FNA; Wilson Cook, Mediglobe) were performed in standarde fashion; solid cylindric material gained by introducing the stylet into the needle was sent for histology, whereas the remaining fluid material was smeared for cytologic analysis. Results: Material suitable for cytological analysis was obtained in 96,1%, whereas this rate was only 74,6% for histology. Final diagnosis including independent tissue confirmation or follow-up was adenocarcinoma n Z 54; neuroendocrine tumour n Z 5; other malignant tumour n Z 8, inflammatory lesions n Z 37. Sensitivity and specificity for the diagnosis of malignancy were 74,6% and 94,7% (cytology) and 58,2% and 89,2% (histology). In the subgroup of adequate specimens sensitivities and specificities were similar (cytology 78,1% and 100%, histology 69,6% and 97,5%). The combination of both methods increased sensitivity to 85.2% (specificity 97,2%). A specific tumor tissue characterization was possible in 20-41% by cytology and 25-44% by histology depending on tumor type. Summary/Conclusions: Due to a higher percentage of insufficient material, sensitivity and specificity of EUS-FNA-histology in pancreatic tumors were lower than those of EUS-FNA-cytology. The combination of both techniques improved the overall results of EUS-FNA.
W1322 A Prospective Study of Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis Combined with Local Chemotherapy for Pancreatic Cancer Pain Yanqing Li, Ning Zhong, Wenjie Li, Hongbo Ren, Youan Zhao
W1324 Does Endoscopic Ultrasonography Influence the Management of Patients with Dilated Common Bile Duct? Shinji Okaniwa, Yoshiyuki Nakamura, Manabu Hiraguri, Naoto Horigome, Gengo Kaneko, Yuko Okaniwa, Nobuo Itoh
Objective: Since the general condition of patients in advanced stage pancreatic cancer is usually too poor to tolerate traditional intravenous chemotherapy, a EUS guide local chemotherapy was developed in order to get long-term control of abdominal pain. The aim of this study was to evaluate the long-term effect of EUSguided celiac plexus neurolysis combined with local chemotherapy on abdominal pain associated with pancreatic cancer. Methods: Twenty-three patients with painful and inoperable pancreatic cancer were evaluated at before and 20 weeks after EUS celiac plexus neurolysis combined with local chemotherapy. EUS CPN was performed with a linear array echoendoscope (Pentax EG3630U, Pentax Precision Instruments) Under direct EUS visualization, After injecting 2 mL of saline solution to clear the needle adjacent and anterior to the lateral aspect of the aorta at the level of the celiac trunk, 10 mL of dehydrated 98% absolute alcohol was injected. The process was then repeated on the opposite side of the aorta. EUS guide local chemotherapy was performed with the same echoendoscope and aspiration needle. Under direct EUS visualization, 1 mg/ml Cisplatin (DDP) solution was injected into tumor tissues directly. The total dose of DDP was about 15 mg for tumors which diameters were less than 40 millimeter, while for tumors larger than 40 millimeter, the total dose increased to 20 mg. Pain scores were assessed with a standardized 11-point continuous visual analog pain scale. Results: The study population consisted of 18 men and 5 women (mean age 57 years; range 48 to 67 years). Of the 23 patients enrolled, 7 had the tumor located in the head of the pancreas, 13 in the body or the tail, and 3 patients had diffuse pancreatic involvement. There were no major complications in both the EUS CPN and EUS guide local chemotherapy. Five patients had transient abdominal pain after the procedure, which persisted less than 48 hours and was relieved by an increase in the dosage of pain medication. 10 patients suffered with male nausea and vomiting after chemotherapy, no bone marrow depression was founded. Overall pain scores decreased significantly after EUS CPN combined with EUS guide local chemotherapy. There were no statistically significant changes of the diameters of the tumors before and after the treatment procedure. Conclusion EUS-guided celiac plexus neurolysis combined with local chemotherapy is effective and safe in long-term control of abdominal pain associated with pancreatic cancer. Potential benefits of this procedure require further investigation to identify advantages of this approach over conventional general intravenous chemotherapy.
Purpose: Precise evaluation of patients with dilated common bile duct (CBD) is extremely important. Computed tomography (CT) shows high sensitivity in detecting dilated CBD as well as the level of obstruction, and is usually used as the first modality. In some cases however, CT can not demonstrate the cause. This study is designed to evaluate the usefulness of endoscopic ultrasonography (EUS) in detecting the cause of CBD dilatation in patients in whom CT could not detect the cause or only revealed equivocal findings. Methods: In this study, we retrospectively analyzed 114 available cases with dilated CBD detected with CT (O9 mm in diameter) between April 2000 and August 2005. Final diagnoses were determined by endoscopic retrograde cholangiopancreatography and surgical exploration, and all cases diagnosed as only dilated CBD were followed up at least 6 months after diagnosed. As CBD stones and biliopancreatic carcinomas (BPC) are determinant factors for the management of patients with CBD dilatation, we evaluate the diagnostic accuracy in detecting these diseases in the following diagnostic processes. First, we evaluated these diseases solely using CT in all cases. When CBD stones were detected, we performed endoscopic treatment without EUS. Second, we performed EUS additionally for all cases and reconsidered the management of patients according to EUS findings. All cases were classified into 3 groups: dilated CBD only, with CBD stones, with BPC. Results: The number of each group was as follows: dilated CBD only, 20 (including post gastrectomy 2, post cholecystectomy 5); with CBD stones, 44; with BPC, 50 (gallbladder carcinoma 2, extra hepatic bile duct carcinoma 24, carcinoma of the ampulla of Vater 8 and pancreatic carcinoma 16). Solely using CT, 10 of 44 cases with CBD stones were misdiagnosed as dilated CBD only and 4 cases with BPC were missed (extra hepatic bile duct carcinoma 2 and ampullary carcinoma 2). So 14 cases were incorrectly diagnosed in total, and the over all accuracy was 87.7% (100/114). EUS was performed in 80 cases, and 10 cases with CBD stones and 4 cases with BPC were correctly diagnosed additionally. So, an additional EUS influenced all 14 misdiagnosed cases. Though CT could reveal equivocal findings in extra hepatic bile duct carcinomas, neither CT nor MRI could detect any findings except for CBD dilatation in non invasive minute ampullary carcinomas. Conclusions: EUS is very useful in detecting the CBD stones and BPC, particularly minute carcinoma of the ampulla of Vater. We recommend EUS in patients in whom CT could not detect any cause or only revealed equivocal findings.
www.giejournal.org
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB267