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Use of Endoscopic Ultrasound in the Evaluation of the Integrity of Nissen Fundoplication
Abstracts
W1231 Comparison of EUS Guided Pancreatic Cyst (PC) Aspirate Cea, DNA Quantity and Quality: Mutational Acquisition Pattern in Predicting Malignancy Asif Khalid, Sydney Finkelstein, Debra Brody, Patricia Swalsky, A.J. Moser, Kenneth K. Lee, Adam Slivka, David C. Whitcomb, Kevin M. McGrath Background: Currently employed methods to diagnose malignancy in pancreatic cysts remain insensitive. Methods: Patients with PC were prospectively enrolled to undergo EUS/FNA with fluid evaluated for (a) cytology exam, (b) CEA level, (c) DNA quantification [optical density {OD} and qPCR for cycle threshold of amplifiable DNA {CT} value calculation], (d) k-ras mutational analysis, (e) broad spectrum tumor suppressor gene linked microsatellite loss targeting 1p36, 3p26, 5q23, 9p21, 10q23, 17p13, 17q23, 21q23, 22q13, and (f) relative timing of mutation acquisition/ microsatellite loss calculation from electroherogram peak height ratios for the normal and mutant allele (based on clonal expansion model of tumorigenesis). The above fluid analysis was compared to the final pathology. Results: Analysis included 36 cysts (11 malignant {8 invasive cancers, 3 carcinoma-in-situ}, 15 premalignant and 10 benign). All benign cysts manifested poor quality DNA with no mutations. Fluid analysis results for malignant and pre-malignant cysts are presented in table. Conclusion: A detailed molecular analysis of pancreatic cyst aspirate incorporating DNA quality and broad spectrum mutational analysis including mutation acquisition pattern helps differentiate pre-malignant from malignant cysts. Initial k-ras mutation followed by LOH is most predictive of a malignant cyst.
W1233 Accuracy of Endoscopic Ultrasonography in Gastric Submucosal Tumors Yong Soo Kim, Hyun Chang, Tae Il Kim, Seung Woo Park, Yong Chan Lee, Si Young Song, Jae Bock Chung Yonsei University College of Medicine, Seoul, Korea, Department of Internal Medicine, Division of Gastroenterology Background: Endoscopic ultrasonography (EUS) is the best imaging method for diagnosing and differentiating between submucosal tumors in the gastrointestinal (GI) tract. Submucosal tumor (SMT) is good indication for minimal invasive surgery such as endoscopic or laparoscopic resection, and its definite diagnosis depends on histologic diagnosis. Aim: The aim of this study were to assess diagnostic accuracy of EUS for diagnosis of gastric SMT and to investigate factors affecting diagnostic accuracy of EUS. Patient and Method: From Jan, 2001 through Jun, 2004, 82 patients who had SMT in stomach were enrolled in Severance Hospital, Yonsei University College of Medicine. In every case, histologic diagnosis was confirmed by endoscopic submucosal resection, surgery, and endoscopic biopsy. Result: The overall accuracy rate was observed as 68.3% (56/82). The pathologic diagnosis revealed gastrointestinal stromal tumor (GIST), leiomyoma, neurogenic tumor, ectopic pancreas, inflammatory fibroid polyp (IFP) and other benign condition. GIST was the most common SMT found in stomach. GIST showed relatively high accuracy rate(75.4%) than leiomyoma(47.6%). The leiomyoma was often misdiagnosed as GIST.
The accuracy of EUS for predicting pathologic diagnosis based on EUS finding is relatively high, however, EUS is still inadequate for differential diagnosis between GIST and leiomyoma/neurogenic tumor.
W1232 Use of Endoscopic Ultrasound in the Evaluation of the Integrity of Nissen Fundoplication Charles Kim, Ann Seltman, Blair A. Jobe, Deepak Gopal, Raquel Davila Background: The accurate evaluation of patients with recurrent GERD symptoms after anti-reflux surgery is challenging. Aim: To determine the feasibility, safety and utility of endoscopic ultrasound (EUS) in the evaluation of the anatomic integrity of Nissen fundoplication (NF). Methods: Asymptomatic patients R3 mo post NF were prospectively enrolled. All subjects had normal 24-hr pH, esophageal manometry, and upper GI studies. An EGD was performed prior to EUS to evaluate the NF and to rule out esophagitis. EUS was performed by the same endoscopist in all patients using the Olympus GF-UM160 radial echoendoscope. The EUS characteristics of an intact NF were previously established in a pilot study using a swine model after NF. Based on that study, an intact NF is characterized by 5 alternating echorich and echopoor layers representing: 1) esophageal wall, 2) space between the esophagus and NF, 3) inner gastric wall of the NF, 4) gastric lumen and 5) outer gastric wall. Results: 8 patients (7M, 1F) were enrolled over 3 mo. All patients had an intact NF and no esophagitis or hiatal hernia on EGD. EUS consistently demonstrated an intact 5-layer pattern of NF on all 8 patients. The 5 layers were seen circumferentially around the EUS transducer, which was consistent with a 360 degree wrap. Table 1. shows the anatomical landmarks used to determine the intra-abdominal or intra-thoracic location of the NF. The superior border of the NF below the esophageal hiatus at or below the level of the diaphragm determines an intra-abdominal location. All patients had NF located intra-abdominally. There were no complications. Conclusions: EUS after NF is feasible and safe, and can be used to characterize the key aspects of an intact wrap. Further studies to assess the utility and accuracy of EUS in the evaluation of failed NF are warranted. Table 1. Anatomical landmarks used in determining the location of Nissen fundoplication
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W1234 Clinical Impact of On-Site Cytopathologic Interpretation for Endoscopic Ultrasound Guided Fine Needle Aspiration Timothy Kinney, Jason Klapman, Alberto Larghi, Charles Dye, Vanessa Shami, Roberto Logrono, Lynne Stearns, Irving Waxman Background: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become the procedure of choice for diagnosing gastrointestinal and many thoracic malignancies. Obtaining adequate tissue samples to establish the diagnosis can be problematic, however, without the presence of a cytopathologist on-site during the procedure. We previously demonstrated a trend that the presence of on-site cytopathologist improves the yield of EUS-FNA and reduces the need to subject patients to multiple exams to establish a diagnosis, but due to a limited number of patients did not reach statistical significance. The following is an updated report with two years more data collection. Methods: A retrospective analysis of a prospectively collected database was performed of patients undergoing EUSguided FNA in two institutions. Patient and procedure-related data were recorded, including patient age, gender, number of needle passes to obtain tissue, target site, number of repeat procedures, and cytologic diagnosis. In one institution, a cytopathologist was present for every procedure. In the second institution, an onsite cytopathologist was not routinely available. In this institution, 5 needle passes were routinely taken for solid masses, and 3 passes were taken for nodes and other lesions. Cytologic diagnoses were categorized as positive or negative for malignancy, suspicious for malignancy, atypical/ indeterminate, or unsatisfactory. The presence (group 1) or absence (group 2) of a cytopathologist during the exam was recorded and these groups were compared. Results: 431 patients (129 group 1, 302 group 2) undergoing 552 EUS-guided FNAs (157 group 1, 395 group 2) were evaluated. There were more males in each group (group 1:1.3/1, group 2: 1.1/1), mean age was 59 in group 1 and 63.7 in group 2. The most common biopsy site was thoraco-abdominal nodes in group 1, and pancreas in group 2. Patients in group 1 had a diagnosis of positive or negative for malignancy more frequently (p Z 0.0001) and were less likely to require a repeat procedure to establish a diagnosis. (p Z 0.016) Conclusion: The presence of an on-site cytopathologist for immediate interpretation of specimens during EUS-FNA significantly improves the diagnostic yield, and decreases the need for repeat procedures to establish a diagnosis. Based on these results, EUS centers should consider allocation of resources for on-site cytopathology evaluation.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB287
W1231 Comparison of EUS Guided Pancreatic Cyst (PC) Aspirate Cea, DNA Quantity and Quality: Mutational Acquisition Pattern in Predicting Malignancy Asif Khalid, Sydney Finkelstein, Debra Brody, Patricia Swalsky, A.J. Moser, Kenneth K. Lee, Adam Slivka, David C. Whitcomb, Kevin M. McGrath Background: Currently employed methods to diagnose malignancy in pancreatic cysts remain insensitive. Methods: Patients with PC were prospectively enrolled to undergo EUS/FNA with fluid evaluated for (a) cytology exam, (b) CEA level, (c) DNA quantification [optical density {OD} and qPCR for cycle threshold of amplifiable DNA {CT} value calculation], (d) k-ras mutational analysis, (e) broad spectrum tumor suppressor gene linked microsatellite loss targeting 1p36, 3p26, 5q23, 9p21, 10q23, 17p13, 17q23, 21q23, 22q13, and (f) relative timing of mutation acquisition/ microsatellite loss calculation from electroherogram peak height ratios for the normal and mutant allele (based on clonal expansion model of tumorigenesis). The above fluid analysis was compared to the final pathology. Results: Analysis included 36 cysts (11 malignant {8 invasive cancers, 3 carcinoma-in-situ}, 15 premalignant and 10 benign). All benign cysts manifested poor quality DNA with no mutations. Fluid analysis results for malignant and pre-malignant cysts are presented in table. Conclusion: A detailed molecular analysis of pancreatic cyst aspirate incorporating DNA quality and broad spectrum mutational analysis including mutation acquisition pattern helps differentiate pre-malignant from malignant cysts. Initial k-ras mutation followed by LOH is most predictive of a malignant cyst.
W1233 Accuracy of Endoscopic Ultrasonography in Gastric Submucosal Tumors Yong Soo Kim, Hyun Chang, Tae Il Kim, Seung Woo Park, Yong Chan Lee, Si Young Song, Jae Bock Chung Yonsei University College of Medicine, Seoul, Korea, Department of Internal Medicine, Division of Gastroenterology Background: Endoscopic ultrasonography (EUS) is the best imaging method for diagnosing and differentiating between submucosal tumors in the gastrointestinal (GI) tract. Submucosal tumor (SMT) is good indication for minimal invasive surgery such as endoscopic or laparoscopic resection, and its definite diagnosis depends on histologic diagnosis. Aim: The aim of this study were to assess diagnostic accuracy of EUS for diagnosis of gastric SMT and to investigate factors affecting diagnostic accuracy of EUS. Patient and Method: From Jan, 2001 through Jun, 2004, 82 patients who had SMT in stomach were enrolled in Severance Hospital, Yonsei University College of Medicine. In every case, histologic diagnosis was confirmed by endoscopic submucosal resection, surgery, and endoscopic biopsy. Result: The overall accuracy rate was observed as 68.3% (56/82). The pathologic diagnosis revealed gastrointestinal stromal tumor (GIST), leiomyoma, neurogenic tumor, ectopic pancreas, inflammatory fibroid polyp (IFP) and other benign condition. GIST was the most common SMT found in stomach. GIST showed relatively high accuracy rate(75.4%) than leiomyoma(47.6%). The leiomyoma was often misdiagnosed as GIST.
The accuracy of EUS for predicting pathologic diagnosis based on EUS finding is relatively high, however, EUS is still inadequate for differential diagnosis between GIST and leiomyoma/neurogenic tumor.
W1232 Use of Endoscopic Ultrasound in the Evaluation of the Integrity of Nissen Fundoplication Charles Kim, Ann Seltman, Blair A. Jobe, Deepak Gopal, Raquel Davila Background: The accurate evaluation of patients with recurrent GERD symptoms after anti-reflux surgery is challenging. Aim: To determine the feasibility, safety and utility of endoscopic ultrasound (EUS) in the evaluation of the anatomic integrity of Nissen fundoplication (NF). Methods: Asymptomatic patients R3 mo post NF were prospectively enrolled. All subjects had normal 24-hr pH, esophageal manometry, and upper GI studies. An EGD was performed prior to EUS to evaluate the NF and to rule out esophagitis. EUS was performed by the same endoscopist in all patients using the Olympus GF-UM160 radial echoendoscope. The EUS characteristics of an intact NF were previously established in a pilot study using a swine model after NF. Based on that study, an intact NF is characterized by 5 alternating echorich and echopoor layers representing: 1) esophageal wall, 2) space between the esophagus and NF, 3) inner gastric wall of the NF, 4) gastric lumen and 5) outer gastric wall. Results: 8 patients (7M, 1F) were enrolled over 3 mo. All patients had an intact NF and no esophagitis or hiatal hernia on EGD. EUS consistently demonstrated an intact 5-layer pattern of NF on all 8 patients. The 5 layers were seen circumferentially around the EUS transducer, which was consistent with a 360 degree wrap. Table 1. shows the anatomical landmarks used to determine the intra-abdominal or intra-thoracic location of the NF. The superior border of the NF below the esophageal hiatus at or below the level of the diaphragm determines an intra-abdominal location. All patients had NF located intra-abdominally. There were no complications. Conclusions: EUS after NF is feasible and safe, and can be used to characterize the key aspects of an intact wrap. Further studies to assess the utility and accuracy of EUS in the evaluation of failed NF are warranted. Table 1. Anatomical landmarks used in determining the location of Nissen fundoplication
www.mosby.com/gie
W1234 Clinical Impact of On-Site Cytopathologic Interpretation for Endoscopic Ultrasound Guided Fine Needle Aspiration Timothy Kinney, Jason Klapman, Alberto Larghi, Charles Dye, Vanessa Shami, Roberto Logrono, Lynne Stearns, Irving Waxman Background: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has become the procedure of choice for diagnosing gastrointestinal and many thoracic malignancies. Obtaining adequate tissue samples to establish the diagnosis can be problematic, however, without the presence of a cytopathologist on-site during the procedure. We previously demonstrated a trend that the presence of on-site cytopathologist improves the yield of EUS-FNA and reduces the need to subject patients to multiple exams to establish a diagnosis, but due to a limited number of patients did not reach statistical significance. The following is an updated report with two years more data collection. Methods: A retrospective analysis of a prospectively collected database was performed of patients undergoing EUSguided FNA in two institutions. Patient and procedure-related data were recorded, including patient age, gender, number of needle passes to obtain tissue, target site, number of repeat procedures, and cytologic diagnosis. In one institution, a cytopathologist was present for every procedure. In the second institution, an onsite cytopathologist was not routinely available. In this institution, 5 needle passes were routinely taken for solid masses, and 3 passes were taken for nodes and other lesions. Cytologic diagnoses were categorized as positive or negative for malignancy, suspicious for malignancy, atypical/ indeterminate, or unsatisfactory. The presence (group 1) or absence (group 2) of a cytopathologist during the exam was recorded and these groups were compared. Results: 431 patients (129 group 1, 302 group 2) undergoing 552 EUS-guided FNAs (157 group 1, 395 group 2) were evaluated. There were more males in each group (group 1:1.3/1, group 2: 1.1/1), mean age was 59 in group 1 and 63.7 in group 2. The most common biopsy site was thoraco-abdominal nodes in group 1, and pancreas in group 2. Patients in group 1 had a diagnosis of positive or negative for malignancy more frequently (p Z 0.0001) and were less likely to require a repeat procedure to establish a diagnosis. (p Z 0.016) Conclusion: The presence of an on-site cytopathologist for immediate interpretation of specimens during EUS-FNA significantly improves the diagnostic yield, and decreases the need for repeat procedures to establish a diagnosis. Based on these results, EUS centers should consider allocation of resources for on-site cytopathology evaluation.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB287