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Wilkie's syndrome diagnosed by curvilinear array endoscopy ultrasound: an unsuspected entity
Abstracts
a prior NOTES study) was calculated as a sum of 3 adhesion subscores: a) density/ vascularity of adhesions: 0Znone; 1Zfilmy avascular; 2Zdense or vascular; and 3Zdense and vascular; b) Size (width) of largest adhesive band: noneZ0; O4 cmZ3; and c) extent of adhesions: 0Znone, 1Z1 2-organ pair (e.g. celiac to stomach), 2Z2 2-organ pairs, 3Z3 or more 2-organ pairs. Results: All pigs thrived after EUS-guided celiac injection, with non-survival pancreatic surgery at 6-14 days. All pancreatic surgeries were completed successfully. Two of the 5 CPB pigs had adhesions that involved the pancreas in some way. Although the overall adhesion score was higher (Mann Whitney p Z 0.06) in the CPN group (4.6) vs. CPB (0) vs. controls (0), there was no recorded interference with surgery (or vascular plane identification) in any of the 3 groups, except minor interference in one CPB pig. Conclusions: A single celiac plexus (alcohol) neurolysis procedure, not surprisingly, causes peri-celiac adhesion formation; however, the adhesions do not appear to interfere with subsequent pancreatic surgery in a pig survival model. Celiac neurolysis may have a role in chronic.
Downstream financial benefits of EUS to a single medical center Matthew Atkinson Purpose: Endoscopic ultrasound (EUS) has proven to be a clinically valuable platform. One possible barrier to more widespread use, however, is modest reimbursement rates relative to procedural time. We hypothesized that the number of downstream procedures generated by EUS for a single institution would be greater than that produced by colonoscopy, and that this difference might offset the reimbursement advantage for colonoscopy. Methods: We retrospectively reviewed 920 consecutive EUS’s and 920 consecutive colonoscopies at the University of Cincinnati (UC) to determine the downstream procedures generated for the institution within 18 months of the index procedure. A downstream procedure was included only if it was a direct result of the findings on the EUS or colonoscopy and if it would not have been performed at UC in the absence of that EUS or colonoscopy. Further procedures that were performed after the original downstream procedure were excluded. Medicare Allowable Charges were assigned to actual CPT codes for endoscopic procedures, radiation oncology, and interventional radiology. Twenty of the surgeries were reviewed for actual CPT codes and an average charge per surgery was generated. Average charges for each chemotherapy regimen were also calculated. Medicare allowable charges for consults were averaged between level 4 and level 5 visits and applied to all consults. Results: Overall, EUS led to a greater number of downstream procedures than colonoscopy (218 vs. 62). EUS led to a greater number of surgeries and surgical consults than colonoscopy (63 vs. 25), a greater number of patients referred for chemotherapy (30 vs. 2), a greater number of patients referred for radiation therapy (15 vs. 0), a greater number of patients referred for interventional radiology procedures (3 vs. 0), and a greater number of patients referred for endoscopic procedures (107 vs. 35). Total downstream professional charges were greater for EUS than colonoscopy ($204,825.59 vs. $42,124.36). Professional charges created by EUS were greater for surgery ($82,731.68 vs. $33,060.50), for radiation oncology ($25,718.70 vs. $0), for oncology ($23,229.13 vs. $0), for interventional radiology ($3027.07 vs. $0), and for gastroenterology ($73,119.01 vs. $8,739.54). Total physician charges for the original 920 EUS’s was greater than the original 920 colonoscopies ($324,241.85 vs. $209,805.73). Overall, total physician charges for the 920 EUS’s and their downstream procedures was 2.1 times greater than total physician charges for the 920 colonoscopies and their downstream procedures ($529,067.44 vs. $251.930.09). Conclusions: While reimbursement for a half-day of EUS is lower than a half-day of colonoscopy, the downstream procedures and professional charges generated by EUS for the institution appear to attenuate this difference.
Endoscopic ultrasound directed pseudocyst drainage without the use of fluoroscopy: a case series Kamran Ayub, D. Patterson, S. Irani, D. Schembre, M. Gluck, J. Brandabur, G. Jiranek, A. Ross, O. Lin, R. Kozarek Background & Aim: Endoscopic drainage of pancreatic pseudocysts is usually performed using fluoroscopy and a therapeutic duodenoscope. Endoscopic ultrasound (EUS) is often used to choose the puncture site and avoid penetrating a vessel. However, fluoroscopy and EUS equipment are typically in separate rooms making transport of EUS equipment difficult and cumbersome. Also, availability of a fluoroscopy suite can be an issue at many institutions. The aim of this study was to evaluate the technical feasibility and safety of EUS directed pseudocyst drainage without the use of fluoroscopy. Methods: Consecutive patients referred for pseudocyst drainage to one endosonographer between July 2004 and November 2007 were managed by cyst drainage using EUS guidance without the use of fluoroscopy. Technical success rate and complications were reviewed. In addition, previous attempts at drainage were recorded. Fifteen procedures were performed using the Olympus GF-UC140P echoendoscope; one procedure was performed using the Suzi GFUCT160 therapeutic echoendoscope. In each case initial puncture was made using a 19-G needle and fluid was aspirated. A .035 wire was passed through the needle into the cyst. The tract was dilated over the wire using a 4.5 to 6 F graduated dilator; balloon dilation was then
S234 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
performed to 8 or 10 mm. One to 4 stents were placed. Either 7 F x 3 cm or 5 cm double pigtail stents were used. An ERCP trained nurse was required for the procedure. All procedures were performed only with an echoendoscope. Results: A total of 16 patients were managed with this technique. The procedure was unsuccessful in one of 16 patients due to difficulty with sedation. Three patients had previous failed attempts at cyst drainage by ERCP experts using fluoroscopy and a therapeutic duodenoscope. EUS guided drainage was successful in all three of these patients. There were 3 complications: one patient had delayed bleeding requiring transfusion; this patient was known to have varices in the pseudocyst. One patient had stent migration into the cyst; this was removed at a later date without any untoward consequences. A third patient had one of two stents slip out of the cyst due to initial wire loss; this was removed without any complications. Conclusions: EUS directed pseudocyst drainage without the use of fluoroscopy appears technically feasible and safe.
Wilkie’s syndrome diagnosed by curvilinear array endoscopy ultrasound: an unsuspected entity Dervis Bandres, Olaya Brewer, Olga Roman, Saturnino Fernandez Aim: The purpose of this case report is to show the feasibility of curvilinear endoscopic uitrasound (C-EUS) as a diagnostic tool in Wilkie´s syndrome. Case Report. Female patient, 17 YO, who was evaluated for postprandial epigastric discomfort since 2 years, with fullness, early satiety and nausea, no vomits, decreasing food ingestion with weight loss. Patient consulted to a paediatrician and nutritionist in different occasions without improving. Physical examination: BP 90/60 mmHg. Pulse 66 x min. Weight 34 kg. Height 1.56 m. BMI 13.99. No abdominal mass. No liver or spleen enlargement. Lab tests: abdominal ultrasound and upper barium swallow without abnormalities. An upper endoscopy was done finding an antral, 12 mm, sub epithelial lesion in the greater curvature. She was referred for C-EUS, showing a lesion located in the deep mucosa. We evaluated the gallbladder, pancreas and liver without abnormalities. The Superior Mesenteric Artery (SMA) showed an angle of emergence of 18 (normal O25 ), suspecting a Wilkie´s syndrome. To confirm the diagnosis we made a CT scan angiography (GE multidetector scan) confirming the diagnosis. Recommendations to gain weight as specific position after food ingestion and hypercaloric diet were indicated. After 7 months of follow up, patient won 4 kg, improving 50% of her symptoms. Postprandial nausea persists, especially after lunch. ´s syndrome is a rare condition with an incidence of 0.13 to 0.33% Conclusion: Wilkie in barium swallows. Over 400 cases have been reported in the english literature. To our knowledge this is the first case diagnosed by C- EUS. This is an excellent technique, not only for therapeutic but also for diagnostic purposes, allowing the endosonographer to diagnose rare and difficult conditions. As shown in this report, ´s syndrome should be kept in mind in those patients referred for EUS, with Wilkie unspecific abdominal symptoms and low weight when other diagnostic methods have failed. C-EUS may be easier and better than radial EUS or miniprobes for the diagnosis of this entity, since we can detail the emergence of the SMA from the Aorta, measuring the angle and the distance between its posterior wall and the Aorta’s anterior wall in an axial view.
Endoscopic ultrasound fine needle aspiration of solid pancreatic lesions in a Venezuelan academic center Dervis Bandres, Olaya Brewer, Victor Bracho, Carolina Dı´az, Victoria Garcı´a, Nelson Simonovich Aim: The purpose of this study is to evaluate the diagnostic accuracy of endoscopic ultrasound fine needle aspiration (EUS-FNA) of pancreatic solid lesions. Method: we searched our computer files all EUSFNAS of solid pancreatic lesions since 2001, done by the same operator, with the Wilson CookÒ needle USN 3 and the Wilson CookÒ Echotip 22G needle, with a PentaxÒ echoendoscope FG 32 UA with a HitachiÒ processor 405 Plus. Specimen adequacy was evaluated by a cytopathologist and then analyzed by a pathologist. Final diagnosis was obtained by surgery, medical treatment or after a mean clinical follow up of 2 years, including patients who died of the disease. We calculated accuracy, sensitivity, specificity, positive and negative predictive value and likelihood ratio, with a 95% confidence interval. Data was analyzed with SPSS for windows version 15.0. Results: EUSFNAS were obtained in 89 patients, 56.2% women and 43.8% men, mean age 61 years. Lesions were mainly in the head of the pancreas (74%). According to the AJCC TNM staging system, 44.9% were categorized as T3 and 37.1% as T4. Only 3.4% had a benign aspect. The EUSFNA yielded a cytological diagnosis in 93% of patients (83/89). The WC USN 3 needle was used in 16 patients (2001-2004) and the WC Echotip 22G in 73 (2004-2008). Mean number of passes was 2-4 (76.4%). Malignancies were the commonest (82%) and adenocarcinoma the most frequent. We found the final diagnosis in 43 patients of which 18 had surgery, 20 chemotherapy and 5 were observed. No complications were reported. There were 2 perforations of the scope with the WC USN3 needle. Overall, the accuracy, sensitivity, specificity, positive and negative predictive value
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a prior NOTES study) was calculated as a sum of 3 adhesion subscores: a) density/ vascularity of adhesions: 0Znone; 1Zfilmy avascular; 2Zdense or vascular; and 3Zdense and vascular; b) Size (width) of largest adhesive band: noneZ0; O4 cmZ3; and c) extent of adhesions: 0Znone, 1Z1 2-organ pair (e.g. celiac to stomach), 2Z2 2-organ pairs, 3Z3 or more 2-organ pairs. Results: All pigs thrived after EUS-guided celiac injection, with non-survival pancreatic surgery at 6-14 days. All pancreatic surgeries were completed successfully. Two of the 5 CPB pigs had adhesions that involved the pancreas in some way. Although the overall adhesion score was higher (Mann Whitney p Z 0.06) in the CPN group (4.6) vs. CPB (0) vs. controls (0), there was no recorded interference with surgery (or vascular plane identification) in any of the 3 groups, except minor interference in one CPB pig. Conclusions: A single celiac plexus (alcohol) neurolysis procedure, not surprisingly, causes peri-celiac adhesion formation; however, the adhesions do not appear to interfere with subsequent pancreatic surgery in a pig survival model. Celiac neurolysis may have a role in chronic.
Downstream financial benefits of EUS to a single medical center Matthew Atkinson Purpose: Endoscopic ultrasound (EUS) has proven to be a clinically valuable platform. One possible barrier to more widespread use, however, is modest reimbursement rates relative to procedural time. We hypothesized that the number of downstream procedures generated by EUS for a single institution would be greater than that produced by colonoscopy, and that this difference might offset the reimbursement advantage for colonoscopy. Methods: We retrospectively reviewed 920 consecutive EUS’s and 920 consecutive colonoscopies at the University of Cincinnati (UC) to determine the downstream procedures generated for the institution within 18 months of the index procedure. A downstream procedure was included only if it was a direct result of the findings on the EUS or colonoscopy and if it would not have been performed at UC in the absence of that EUS or colonoscopy. Further procedures that were performed after the original downstream procedure were excluded. Medicare Allowable Charges were assigned to actual CPT codes for endoscopic procedures, radiation oncology, and interventional radiology. Twenty of the surgeries were reviewed for actual CPT codes and an average charge per surgery was generated. Average charges for each chemotherapy regimen were also calculated. Medicare allowable charges for consults were averaged between level 4 and level 5 visits and applied to all consults. Results: Overall, EUS led to a greater number of downstream procedures than colonoscopy (218 vs. 62). EUS led to a greater number of surgeries and surgical consults than colonoscopy (63 vs. 25), a greater number of patients referred for chemotherapy (30 vs. 2), a greater number of patients referred for radiation therapy (15 vs. 0), a greater number of patients referred for interventional radiology procedures (3 vs. 0), and a greater number of patients referred for endoscopic procedures (107 vs. 35). Total downstream professional charges were greater for EUS than colonoscopy ($204,825.59 vs. $42,124.36). Professional charges created by EUS were greater for surgery ($82,731.68 vs. $33,060.50), for radiation oncology ($25,718.70 vs. $0), for oncology ($23,229.13 vs. $0), for interventional radiology ($3027.07 vs. $0), and for gastroenterology ($73,119.01 vs. $8,739.54). Total physician charges for the original 920 EUS’s was greater than the original 920 colonoscopies ($324,241.85 vs. $209,805.73). Overall, total physician charges for the 920 EUS’s and their downstream procedures was 2.1 times greater than total physician charges for the 920 colonoscopies and their downstream procedures ($529,067.44 vs. $251.930.09). Conclusions: While reimbursement for a half-day of EUS is lower than a half-day of colonoscopy, the downstream procedures and professional charges generated by EUS for the institution appear to attenuate this difference.
Endoscopic ultrasound directed pseudocyst drainage without the use of fluoroscopy: a case series Kamran Ayub, D. Patterson, S. Irani, D. Schembre, M. Gluck, J. Brandabur, G. Jiranek, A. Ross, O. Lin, R. Kozarek Background & Aim: Endoscopic drainage of pancreatic pseudocysts is usually performed using fluoroscopy and a therapeutic duodenoscope. Endoscopic ultrasound (EUS) is often used to choose the puncture site and avoid penetrating a vessel. However, fluoroscopy and EUS equipment are typically in separate rooms making transport of EUS equipment difficult and cumbersome. Also, availability of a fluoroscopy suite can be an issue at many institutions. The aim of this study was to evaluate the technical feasibility and safety of EUS directed pseudocyst drainage without the use of fluoroscopy. Methods: Consecutive patients referred for pseudocyst drainage to one endosonographer between July 2004 and November 2007 were managed by cyst drainage using EUS guidance without the use of fluoroscopy. Technical success rate and complications were reviewed. In addition, previous attempts at drainage were recorded. Fifteen procedures were performed using the Olympus GF-UC140P echoendoscope; one procedure was performed using the Suzi GFUCT160 therapeutic echoendoscope. In each case initial puncture was made using a 19-G needle and fluid was aspirated. A .035 wire was passed through the needle into the cyst. The tract was dilated over the wire using a 4.5 to 6 F graduated dilator; balloon dilation was then
S234 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009
performed to 8 or 10 mm. One to 4 stents were placed. Either 7 F x 3 cm or 5 cm double pigtail stents were used. An ERCP trained nurse was required for the procedure. All procedures were performed only with an echoendoscope. Results: A total of 16 patients were managed with this technique. The procedure was unsuccessful in one of 16 patients due to difficulty with sedation. Three patients had previous failed attempts at cyst drainage by ERCP experts using fluoroscopy and a therapeutic duodenoscope. EUS guided drainage was successful in all three of these patients. There were 3 complications: one patient had delayed bleeding requiring transfusion; this patient was known to have varices in the pseudocyst. One patient had stent migration into the cyst; this was removed at a later date without any untoward consequences. A third patient had one of two stents slip out of the cyst due to initial wire loss; this was removed without any complications. Conclusions: EUS directed pseudocyst drainage without the use of fluoroscopy appears technically feasible and safe.
Wilkie’s syndrome diagnosed by curvilinear array endoscopy ultrasound: an unsuspected entity Dervis Bandres, Olaya Brewer, Olga Roman, Saturnino Fernandez Aim: The purpose of this case report is to show the feasibility of curvilinear endoscopic uitrasound (C-EUS) as a diagnostic tool in Wilkie´s syndrome. Case Report. Female patient, 17 YO, who was evaluated for postprandial epigastric discomfort since 2 years, with fullness, early satiety and nausea, no vomits, decreasing food ingestion with weight loss. Patient consulted to a paediatrician and nutritionist in different occasions without improving. Physical examination: BP 90/60 mmHg. Pulse 66 x min. Weight 34 kg. Height 1.56 m. BMI 13.99. No abdominal mass. No liver or spleen enlargement. Lab tests: abdominal ultrasound and upper barium swallow without abnormalities. An upper endoscopy was done finding an antral, 12 mm, sub epithelial lesion in the greater curvature. She was referred for C-EUS, showing a lesion located in the deep mucosa. We evaluated the gallbladder, pancreas and liver without abnormalities. The Superior Mesenteric Artery (SMA) showed an angle of emergence of 18 (normal O25 ), suspecting a Wilkie´s syndrome. To confirm the diagnosis we made a CT scan angiography (GE multidetector scan) confirming the diagnosis. Recommendations to gain weight as specific position after food ingestion and hypercaloric diet were indicated. After 7 months of follow up, patient won 4 kg, improving 50% of her symptoms. Postprandial nausea persists, especially after lunch. ´s syndrome is a rare condition with an incidence of 0.13 to 0.33% Conclusion: Wilkie in barium swallows. Over 400 cases have been reported in the english literature. To our knowledge this is the first case diagnosed by C- EUS. This is an excellent technique, not only for therapeutic but also for diagnostic purposes, allowing the endosonographer to diagnose rare and difficult conditions. As shown in this report, ´s syndrome should be kept in mind in those patients referred for EUS, with Wilkie unspecific abdominal symptoms and low weight when other diagnostic methods have failed. C-EUS may be easier and better than radial EUS or miniprobes for the diagnosis of this entity, since we can detail the emergence of the SMA from the Aorta, measuring the angle and the distance between its posterior wall and the Aorta’s anterior wall in an axial view.
Endoscopic ultrasound fine needle aspiration of solid pancreatic lesions in a Venezuelan academic center Dervis Bandres, Olaya Brewer, Victor Bracho, Carolina Dı´az, Victoria Garcı´a, Nelson Simonovich Aim: The purpose of this study is to evaluate the diagnostic accuracy of endoscopic ultrasound fine needle aspiration (EUS-FNA) of pancreatic solid lesions. Method: we searched our computer files all EUSFNAS of solid pancreatic lesions since 2001, done by the same operator, with the Wilson CookÒ needle USN 3 and the Wilson CookÒ Echotip 22G needle, with a PentaxÒ echoendoscope FG 32 UA with a HitachiÒ processor 405 Plus. Specimen adequacy was evaluated by a cytopathologist and then analyzed by a pathologist. Final diagnosis was obtained by surgery, medical treatment or after a mean clinical follow up of 2 years, including patients who died of the disease. We calculated accuracy, sensitivity, specificity, positive and negative predictive value and likelihood ratio, with a 95% confidence interval. Data was analyzed with SPSS for windows version 15.0. Results: EUSFNAS were obtained in 89 patients, 56.2% women and 43.8% men, mean age 61 years. Lesions were mainly in the head of the pancreas (74%). According to the AJCC TNM staging system, 44.9% were categorized as T3 and 37.1% as T4. Only 3.4% had a benign aspect. The EUSFNA yielded a cytological diagnosis in 93% of patients (83/89). The WC USN 3 needle was used in 16 patients (2001-2004) and the WC Echotip 22G in 73 (2004-2008). Mean number of passes was 2-4 (76.4%). Malignancies were the commonest (82%) and adenocarcinoma the most frequent. We found the final diagnosis in 43 patients of which 18 had surgery, 20 chemotherapy and 5 were observed. No complications were reported. There were 2 perforations of the scope with the WC USN3 needle. Overall, the accuracy, sensitivity, specificity, positive and negative predictive value
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