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Background and Aims: Recent legislation passed in July 2001 provides coverage for all Medicare beneficiaries for average-risk screening colonoscopy., Methods: We analyzed the Clinical Outcomes Research Initiative national endoscopic database to characterize colonoscopy practice patterns before and after the introduction of this coverage., Results: Between January 1998 and May 2002, 205,638 patients underwent colonoscopy, of whom 8.3% underwent average-risk colon cancer screening. The proportion of procedures performed for average-risk screening has increased dramatically from 4.6% (before July 2001) to 14.2% (after July 2001). With the increased volume of average-risk screening examinations, colonic lesion detection (masses and polyps greater than 9 mm) has declined (4.9% before July 2001 to 3.8% after July 2001)., Conclusions: There has been a dramatic increase in the rates of screening colonoscopy during the past 4 years. If rates continue to increase, optimal resource utilization will assume increasing importance.

Background: Both endoluminal gastroplication and radiofrequency coagulation of the lower esophageal sphincter and gastroesophageal junction (Stretta procedure) represent emerging endoscopic therapies for GERD. The economic impact of endotherapy for GERD has not been described. The aim of this study was to apply a decision analysis model to compare the costs of endoluminal gastroplication vs. the Stretta procedures vs. a proton pump inhibitor for treatment of GERD. A cost minimization approach was used., Methods: Model entry criteria were GERD responsive to daily or twice daily administration of a proton pump inhibitor. Performance characteristics of endotherapy were determined from published data. The baseline probabilities for annual endotherapy failure rates (20%), partial failure rates (10%), and complication rates (1%) were varied through a plausible range by using sensitivity analysis. Cost data for endotherapy were calculated from per case instrumentation costs plus professional fees plus facility fees for ambulatory patient classification codes; cost of treatment with a proton pump inhibitor was based on national average wholesale price. The endpoint was sustained resolution of GERD symptoms., Results: In patients requiring twice daily use of a proton pump inhibitor for symptom relief, endotherapy proves to be the most economical strategy after 17 months. If uniform endotherapy failure rates over time are assumed, medication regains superiority after 29 months. Sensitivity analysis revealed that a proton pump inhibitor remains the most economical option beyond 3 years, provided annual endotherapy failure rates remain greater than 20% (endoluminal gastroplication) or 19% (Stretta). Pharmacotherapy is the least costly approach, irrespective of time, if the daily cost of a proton pump inhibitor is less than $140 a month or endotherapy costs more than $3400. For patients in whom symptoms are relieved with once daily dosing with a proton pump inhibitor, medication remains the most economical option regardless of endotherapy failure rate., Conclusion: Endotherapy appears to offer an economical treatment option for patients requiring a proton pump inhibitor twice daily, with its cost superiority enduring for 2.5 years. More long-term follow-up data are required to determine the durability of the endotherapy benefit over time.

Objectives: Several large population studies assessing the yield of average risk screening colonoscopy have evaluated Veterans Affairs (VA) populations. It remains uncertain how generalizable these findings are to men in the general population. The aim of this study was to define the prevalence of advanced neoplasia in male patients undergoing screening colonoscopy in diverse practice settings., Methods: The Clinical Outcomes Research Initiative (CORI) national endoscopic database was analyzed to compare the findings in men undergoing average risk screening colonoscopy in community, academic, and VA endoscopy settings., Results: Between January, 1998, and May, 2002, a total of 9109 men underwent screening colonoscopy in community (5625), academic (2269), and VA (1215) settings. Overall yield of colonic lesions (mass or polyp >9 mm) on average risk colonoscopy was 5.1%; 5.7% (community), 3.4% (academic), and 5.9% (VA) in each site, respectively. Among patients with lesions identified, multiple lesions >9 mm were less common in academic settings (6.4%) compared to community (12.0%) or VA (8.9%) sites. When adjusting for age and ethnicity on multivariate analysis, colonic lesion detection at VA sites was similar to community settings. However, lesion identification was more likely in both settings (VA: OR = 1.72; community: OR = 1.56) compared to academic centers., Conclusions: Age- and race-adjusted prevalence of polyps >9 mm in men who receive screening colonoscopy was significantly lower in academic sites compared to VA and community practice sites. One must be cautious in generalizing the findings of male patient studies from academic centers to the entire population.

Background: Push enteroscopy is a well-established technique for evaluation of the small intestine. However, looping of the enteroscope within the stomach limits depth of insertion. Stiffening overtubes that minimize gastric looping are tolerated marginally by patients and disliked by endoscopists. A variable stiffness instrument has the potential to eliminate the need for an overtube while still minimizing gastric looping. The performance of a prototype variable stiffness enteroscope was compared prospectively with that of a conventional push enteroscope with and without use of an overtube., Methods: Consecutive patients undergoing enteroscopy were randomized to have the procedure with a variable stiffness instrument, a conventional instrument with overtube, or a conventional instrument without overtube. Depth of insertion distal to the ligament of Treitz was determined by plain abdominal radiography., Observations: In total, 67 patients were randomized to variable stiffness enteroscopy (25 patients), enteroscopy with overtube (23 patients), and enteroscopy without overtube (19 patients). Median depth of insertion distal to the ligament of Treitz, respectively, for each group, was 89 cm, 68 cm and 41 cm (p = 0.03). In multivariate analysis, variable stiffness instrument use was predictive of intubation to 65 cm distal to the ligament of Treitz (odds ratio 5.53: 95% CI [1.25, 31.25] vs. no overtube, and odds ratio 2.50: 95% CI [0.63, 11.1] vs. overtube). Procedure duration and overall patient tolerance did not differ significantly among the 3 groups, although more patients in the overtube group required additional sedation than patients in the variable stiffness group (p = 0.03). Both endoscopists' (r = 0.34) and nurses' (r = 0.36) estimates of patient discomfort during the procedure correlated poorly with patient tolerance., Conclusions: A variable stiffness push enteroscope enhances insertion depth compared with the conventional instrument with or without overtube. Further studies are required to determine whether this improved performance increases diagnostic yield.

Background: Much attention has been focused on the competence to perform endoscopic procedures. The aim of this study was to determine the impact of procedure experience on patient outcomes after endoscopic pancreatic fluid collection drainage., Methods: Outcomes for consecutive patients with symptoms from pancreatic fluid collections who were referred for endoscopic transmural and/or transpapillary drainage were analyzed retrospectively. Collections were classified as acute pseudocyst, chronic pseudocyst, and pancreatic necrosis. To assess the impact of endoscopist experience, outcomes for patients who underwent the first 20 procedures were compared with those for patients who had subsequent procedures., Results: In total, 175 patients underwent pancreatic fluid collection drainage; 40 (23%) acute pseudocyst, 78 (44%) chronic pseudocyst, and 57 (33%) pancreatic necrosis. Procedure complication rates, collection recurrence rates, and patient outcomes after acute pseudocyst drainage were independent of endoscopist experience. There was a dramatic improvement in chronic pseudocyst resolution rates after the first 20 procedures versus subsequent procedures (45% vs. 93%; p = 0.0002) and a reduction in days to resolution (50 days, initial 20 procedures vs. 33.5 days, subsequent procedures; p = 0.05). In patients with pancreatic necrosis, there was a decrease in median hospital stay with greater experience (23 days to 15 days; p = 0.04)., Conclusions: Resolution of chronic pseudocyst after endoscopic drainage improves markedly with increasing endoscopist experience. Future prospective studies assessing skill acquisition are required to define the minimum number of collection drainage procedures at which competence can be achieved.

Background: Suboptimal bowel preparation for colonoscopy can lead to missed colonic lesions. The aim of this study was to describe the impact of preparation quality on detection of suspected colonic neoplasia., Methods: Data from the Clinical Outcomes Research Initiative national endoscopic database for the period January 1, 2000 to December 31, 2001, were analyzed. Patient demographics, quality of preparation, and colonoscopy findings were abstracted from the database., Results: Overall, 93,004 colonoscopies with adequate documentation were reviewed. Preparation was adequate for 71,501 (76.9%) of these procedures. On multivariate analysis, preparation adequacy was associated with colonic lesion detection, odds ratio (OR) 1.21: 95% CI [1.16, 1.25]. Adequate preparation demonstrated a closer association with identification of "nonsignificant" lesions (polyps 9 mm), OR 1.05: 95% CI [0.98, 1.11]., Conclusions: Bowel preparation is inadequate for almost a quarter of patients undergoing colonoscopy. These results suggest that inadequate preparation quality only hinders detection of smaller lesions, while having negligible impact on detection of larger lesions. These results should be confirmed in prospective studies.

Objectives: The dramatic growth of the World Wide Web (Web) holds potential for use in survey distribution and submission. Its use has not previously been studied in the context of patient satisfaction with endoscopy procedures. In this study we compared standard mail, telephone, and Web-based modes of endoscopy satisfaction survey administration with respect to response rate and response content., Methods: An endoscopy satisfaction questionnaire consisting of seven core items from the modified Group Health Association of America (GHAA-9) was distributed to patients after routine outpatient endoscopy. Patients were randomized to receive the questionnaire by standard mail, telephone, or Web (if applicable). Response rates and satisfaction scores in the groups were compared. The nonresponders to the standard mail and Web surveys were subsequently contacted by telephone to determine their level of satisfaction., Results: Response rates to the telephone survey (81% among those designated as non-Web users and 78% among Web users) and standard mail (75% non-Web users, 67% Web users) were higher than response rate to the Web-based survey (34%) (p < or = 0.0005). There was no significant difference in satisfaction scores among the groups or between satisfaction of nonresponders and responders., Conclusions: The potential of our Web-based survey was limited by poor response rates. This arose from privacy protection precautions that complicated access to the Web site. Future Web-based strategies for surveying patients will need to be more user-friendly while maintaining the intent of the recent Health Insurance Portability and Accountability Act regulations.

Our purpose was to describe the clinical features of patients with novel Yersinia species. Between 1985 and 1999; 194 patients had yersinia species isolated from stool specimens, 38 (20%) had non-Yersinia enterocolitica species; 12 (32%) had Yersinia intermedia, 7 (18%) Yersinia fredericksenii, 3 (8%) Yersinia kristensenii, and the remaining 16 (42%) were unclassified non-Yersinia enterocolitica species. The most common presenting symptom was diarrhea alone in 10 (26.3%) patients. Symptoms persisted for >1 month in 54% of cases; 21% had symptoms for <1 week; 18 (47%) patients were taking corticosteroids, acid suppressants, and/or antibiotics when Yersinia was isolated. An immunocompromised state was present in 11 (29%) patients. An immunocompromised host and administration of acid suppressants predicted persistence of symptoms for >1 month. Most [27 (71%)] patients received no treatment; 5 (13%) received antibiotics. In conclusion, novel non-Yersinia enterocolitica species, including Yersinia intermedia, Y. fredericksenii, and Y. kristensenii may represent up to 20% of all Yersinia isolates. Diarrhea is the most common symptom.

The application of EUS has improved the way we evaluate and manage patients with rectal cancer. EUS has substantially greater sensitivity than CT in detecting advanced T stage tumors. Such improved sensitivity results in changes in preoperative therapy that would not otherwise have occurred without EUS. Although the addition of FNA provides little incremental effect on patient management, it carries the most potential for impacting management in those patients with early T stage disease, and its use should be considered in this subgroup of patients. Whether the accurate staging ability of EUS translates into improved outcomes in terms of reduced recurrence rates and ultimately prolonged survival remains uncertain. This will require further long-term outcome studies focusing on the endpoint of tumor recurrence and patient survival.

Objectives: Medicare beneficiaries now have access to screening colonoscopy (SC). For colon cancer screening to be fruitful, SC must become more acceptable to a broad segment of this population. However, we currently lack knowledge of which aspects of SC have an impact on patient acceptance. The aims of this study were: 1) to identify the features of SC that are most important in deterring participation, and 2) to prioritize and to compare the perceptions of never-screened individuals with those of individuals previously screened for colon cancer., Methods: Questionnaires were distributed to 300 outpatients at Mayo Clinic, Rochester (150 never-screened patients; 150 previously screened patients). The survey instrument addressed domains of the Health Belief Model and colon cancer risk perception. Patients ranked the three most important barriers to SC and answered general knowledge questions on colon cancer., Results: Response rates of never-screened (84%) and screened (88%) patients were similar. Never-screened patients were less likely to have a regular primary physician (80% vs 95%, p = 0.0003) and were less likely to have undergone a prior screening mammography (87% vs 96% of women, p = 0.02) compared with screened patients. The four most reported deterrents to SC ("volume of bowel preparation," "adequate analgesia," "no recommendation from primary physician," and "embarrassment") were ranked similarly by both groups. Never-screened patients had less understanding of the incidence and treatment outcomes of colon cancer., Conclusion: Colon cancer screening behavior seems to be associated with having a regular primary physician, as well as other cancer screening behaviors. Knowledge of colon cancer is the most reliable discriminator of prior screening status. There does not seem to be any difference in the preferences expressed by never-screened and screened patients with respect to the aspects of colonoscopy that they find objectionable.

Objective: Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO., Methods: Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment., Results: A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038., Conclusions: Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.

Background: Jejunostomy tubes can be placed endoscopically by means of percutaneous gastrostomy with jejunal extension (PEG-J) or by direct percutaneous jejunostomy. These 2 techniques were retrospectively compared in patients requiring long-term jejunal feeding., Method: An endoscopy database was used to identify all patients who underwent endoscopic jejunal feeding tube placement from January 1996 to May 2001. Patients with a history of upper GI surgery were excluded. There were 56 patients with a direct percutaneous jejunostomy and 49 with a percutaneous gastrostomy with jejunal extension. Patients in the direct percutaneous jejunostomy group received a 20F direct jejunostomy tube; a 20F PEG tube with a 9F jejunal extension was used in the percutaneous gastrostomy with jejunal extension group. Medical records for the period of 6 months after establishment of jejunal access were reviewed. Complications and need for further endoscopic intervention within this time frame were recorded. The duration of feeding tube patency (number of days from established jejunal access to first endoscopic reintervention) was compared for both groups., Results: Feeding tube patency was significantly longer in patients who had a direct percutaneous jejunostomy compared with those with a percutaneous gastrostomy with jejunal extension. Within the 6-month period, 5 patients with a direct percutaneous jejunostomy required endoscopic reintervention for tube dysfunction compared with 19 patients who had a percutaneous gastrostomy with jejunal extension (p < 0.0001)., Conclusions: For patients who require long-term jejunal feeding, a direct percutaneous jejunostomy with a 20F tube provides more stable jejunal access compared with a percutaneous gastrostomy with jejunal extension with a 9F extension and has a lower associated rate of endoscopic reintervention.

Background: The aims of this study were to determine the feasibility, safety, and yield of a 19-gauge EUS-guided-trucut needle for obtaining biopsy specimens of perigastric organs., Methods: The study was performed in swine under general anesthesia. EUS-guided trucut needle biopsy specimens were obtained from the spleen, liver, pancreas body, and left kidney. Biopsy specimens were assessed for size, fragmentation, and representation of the target organ., Observations: Twenty-eight biopsy specimens were obtained from the 4 target organs with two needles. Median biopsy length was 6 mm (spleen), 4 mm (liver), 6 mm (left kidney), and 2 mm (pancreas body). Of all the specimens, 75% to 100% had tissue representative of the target organ. EUS visualization of the needle was excellent and no complications were identified., Conclusions: Use of the trucut needle under EUS guidance to obtain biopsy specimens of perigastric organs appears safe and yields specimens that are representative of the target organ sampled. Further study of the utility and safety of this needle in humans is warranted.

Objective: Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients., Methods: We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time., Results: All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively (p = 0.05 for groups 1-4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased., Conclusions: Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.

Background & Aims: The influence of preoperative staging of rectal carcinoma on therapeutic decisions is uncertain. The use of fine-needle aspiration (FNA) of perirectal nodes in this setting has not been evaluated. The aim of this prospective, blinded study of patients with rectal cancer was to assess the impact of preoperative staging on treatment decisions and compare the tumor (T), nodal (N) staging performance characteristics of pelvic computed tomography (CT), rectal endoscopic ultrasonography (EUS), and EUS FNA., Methods: Eighty consecutive patients with newly diagnosed rectal cancer were prospectively evaluated. Therapy decisions were recorded after sequential disclosure of staging information to the patient's surgeon., Results: In 31% of patients (95% confidence interval, 21%-42%), EUS staging information changed the surgeon's original treatment plan based on CT alone. The further addition of FNA changed therapy in one patient. T staging accuracy was 71% (CT) and 91% (EUS) (P = 0.02); N staging accuracy was 76% (CT), 82% (EUS), and 76% (EUS FNA) (P = NS)., Conclusions: Preoperative staging with EUS results in more frequent use of preoperative neoadjuvant therapy than if staging was performed with CT alone. The addition of FNA only changed the management of one patient, whereas FNA did not significantly improve N staging accuracy over EUS alone. FNA seems to offer the most potential for impacting management in those patients with early T stage disease, and its use should be confined to this subgroup of patients. EUS is more accurate than CT for determining T stage of rectal carcinoma.

Background: Comparative outcomes after endoscopic drainage of specific types of symptomatic pancreatic fluid collections, defined by using standardized nomenclature, have not been described. This study sought to determine outcome differences after attempted endoscopic drainage of pancreatic fluid collections classified as pancreatic necrosis, acute pseudocyst, and chronic pseudocyst., Methods: Outcomes were retrospectively analyzed for consecutive patients with symptoms caused by pancreatic fluid collections referred for endoscopic transmural and/or transpapillary drainage., Results: Complete endoscopic resolution was achieved in 113 of 138 patients (82%). Resolution was significantly more frequent in patients with chronic pseudocysts (59/64, 92%) than acute pseudocysts (23/31, 74%, p = 0.02) or necrosis (31/43, 72%, p = 0.006). Complications were more common in patients with necrosis (16/43, 37%) than chronic (11/64, 17%, p = 0.02) or acute pseudocysts (6/31, 19%, p = NS). At a median follow-up of 2.1 years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18 of 113 patients (16%). Recurrences developed more commonly in patients with necrosis (9/31, 29%) than acute pseudocysts (2/23, 9%, p = 0.07) or chronic pseudocysts (7/59, 12%, p = 0.047)., Conclusions: Successful resolution of pancreatic fluid collections may be achieved endoscopically by an experienced therapeutic endoscopist. Outcomes differ depending on the type of pancreatic fluid collection drained. Further studies of endoscopic drainage of pancreatic fluid collections must use defined terminology to allow meaningful comparisons.

Objectives: Occasionally alternative techniques such as precut sphincterotomy or percutaneous transhepatic cholangiography (PTC) are required to achieve access to the common bile duct. Tradeoffs exist, however, with respect to their complications and costs. Some experts believe that precut sphincterotomy should not be performed at all. We aimed to compare the cost-effectivenesses of metallic biliary stent placement after an initial failed cannulation attempt at ERCP utilizing precut sphincterotomy and placement utilizing PTC for palliation of jaundice. A cost-effectiveness analysis was performed, as viewed from the societal perspective., Methods: A decision analysis model was designed comparing precut sphincterotomy and PTC approaches for placement of a metallic biliary stent for palliation of jaundice in a patient with inoperable malignant distal biliary obstruction in whom an initial attempt at ERCP cannulation had failed. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. The outcome measured was cost per year of life., Results: Sensitivity analysis showed that precut sphincterotomy with subsequent PTC, if necessary, was the most cost-effective strategy provided the precut complication rate was <51% ($9,033/yr), versus $14,741/yr for PTC., Conclusions: Precut sphincterotomy followed by PTC (if necessary) is the most cost-effective strategy for palliative biliary stenting in the setting of malignant distal biliary obstruction after a failed ERCP attempt. The endoscopic approach is best practiced by experienced endoscopists who minimize precut complication rates.

Objectives: Diagnosis of pancreatic tumors can be problematic. This study aimed to determine the performance of endoscopic ultrasound-guided fine needle aspiration biopsy (EUS FNA) in pancreatic malignancy when prior biopsies performed by CT guidance or ERCP were negative., Methods: A total of 185 patients with known or suspected pancreatic masses were prospectively evaluated with EUS FNA. Before EUS FNA, all patients were evaluated with abdominal CT (61 with CT-guided biopsy) and 91 with ERCP (41 had brushings or biopsy)., Results: EUS had greater sensitivity than CT in detecting a mass (99% vs 57%, p < 0.0001). In 58 patients with negative CT-guided biopsies, EUS FNA had 90% sensitivity for malignancy, 50% specificity for benign disease and 84% accuracy. Similarly, in 36 patients with negative ERCP tissue sampling, results for EUS FNA were 94%, 67% and 92%, respectively. Complications were mild and infrequent (0.5%)., Conclusion: EUS FNA of pancreatic masses safely and accurately diagnoses pancreatic malignancy when prior biopsy techniques have been unsuccessful.

Objective: Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs., Methods: A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively., Results: MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach., Conclusions: The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Background: Identification, staging, and fine needle aspiration of pancreatic mass lesions are probably the most technically demanding EUS skills. This study evaluated the effect of formal training on the diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) of pancreatic masses and the source of the variability in diagnostic accuracy between initial and later procedures., Methods: Sixty-five patients with pancreatic masses underwent EUS-FNA between April 1998 (introduction of EUS-FNA) and August 1999, 20 of whom were examined by 3 endosonographers without prior experience with EUS-FNA. The initial experience of these 3 endosonographers (April to December 1998; group A patients), which included a formal training period of 2 months, and their later experience (January to August 1999; group B patients) were evaluated. Final diagnoses were determined by surgical pathology or clinical follow-up. All EUS-FNA samples were reviewed by 4 blinded pathologists to determine the contribution of pathologist interpretation to varying EUS-FNA accuracy., Results: After a short training period, there was a significant improvement in EUS-FNA accuracy (33% vs. 91%; p = 0.004). After pathology review, good agreement was identified between original FNA interpretation and that on review (kappa = 0.78; 95% CI [0.5, 1.0]). There were differences between the mean cellularity score (2.8 vs. 1.8, p = 0.01) and mean number of passes (5.1 vs. 2.8, not significant) for correct versus incorrect FNA specimens., Conclusion: Significant improvements in EUS-FNA accuracy can be achieved with a short period of mentored training. EUS-FNA errors during the initial learning phase are primarily due to inadequate specimens. Interpretation of pancreatic EUS-FNA specimens remained consistent before and after training.

Objective: Clinical trials demonstrate the superiority of preoperative over postoperative radiotherapy (XRT) in diminishing rates of local recurrence of transmurally infiltrating (T3/4) rectal tumors. The dosage and cost of preoperative XRT are less than postoperative XRT. The economic and health impact of transrectal endoscopic ultrasound (EUS) on rectal cancer management has not been described. The aim of this study was to apply a decision analysis model to compare the cost-effectiveness of three staging strategies in the evaluation of nonmetastatic proximal rectal cancer: abdominal and pelvic CT versus abdominal CT plus EUS versus abdominal CT plus pelvic magnetic resonance imaging., Methods: A decision model was designed using DATA Version 3.5 (TreeAge Software, Williamstown, MA), taking as entry criteria nonmetastatic proximal rectal cancer as determined by abdominal CT. In each arm, detection of transmural invasion prompted preoperative XRT. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional plus facility fees. Endpoints were cost of treatment per patient and tumor recurrence-free rates. Cost-effectiveness (cost per prevention of local recurrence) and incremental cost-effectiveness ratios were calculated., Results: For proximal rectal tumors, evaluation with abdominal CT plus EUS is the most cost-effective approach ($24,468/yr) compared with abdominal CT plus pelvic magnetic resonance imaging ($24,870) and CT alone ($26,076). Both the magnetic resonance imaging- and CT-only approaches were dominated (i.e., more costly and less effective)., Conclusions: Abdominal CT plus EUS is the most cost-effective staging strategy for nonmetastatic proximal rectal cancer. Staging strategies incorporating EUS improve treatment allocation by achieving more accurate T staging, thereby optimizing the benefit of preoperative XRT to more advanced tumors.

Objective: The use of endoscopic ultrasound (EUS) with guided fine needle aspiration (FNA) of suspicious lymph nodes has become an important aid in the staging of esophageal carcinoma. The economic impact of this staging strategy has not yet been described. We applied a decision analysis model to compare the costs of EUS FNA, CT-guided FNA, and surgery in the management of esophageal tumors. A cost-minimization approach was employed, as viewed from the perspective of the payer., Methods: A decision analysis model with three management arms was designed using DATA 3.5 software, taking the entry criteria as esophageal carcinoma without evidence of distant metastases as determined by CT. Detection of tumor on celiac lymph node (CLN) FNA signified unresectability and prompted palliative treatment: chemoradiotherapy with endoscopic esophageal stenting rather than surgery. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional fees plus Medicare facility fees. The endpoint was the cost of management per patient., Results: EUS FNA was the least costly strategy ($13,811), compared to CT FNA ($14,350) and surgery ($13,992). The model outcome was sensitive to changes in both EUS FNA sensitivity and prevalence of CLN metastases. EUS FNA remained the least costly option provided the prevalence of CLN involvement was >16%; below this value, surgery became the most economical strategy., Conclusion: By minimizing unnecessary surgery, primarily by detecting CLN involvement, EUS FNA is the least costly staging strategy in the workup of patients with nonmetastatic esophageal cancer. Under certain circumstances, surgery is the preferred strategy.

Objective: To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC)., Methods: A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT)., Results: The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not., Conclusions: Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

Objective: To compare rates of detection of occult upper gastrointestinal (GI) tract bleeding by guaiac (Hemoccult II [HO]), immunochemical (HemeSelect [HS]), and heme-porphyrin (HemoQuant [HQT]) fecal occult blood tests. PATIENTS, SUBJECTS, AND METHODS: In a cross-sectional study to detect native occult upper GI tract bleeding, single stools were collected from 56 patients with iron deficiency and a proven hemorrhagic GI tract lesion. In a longitudinal study to detect simulated occult upper GI tract bleeding, 3 stool samples were serially collected from 10 clinically normal subjects after ingestion of 5 and 15 mL of autologous blood. All stool samples were subjected to blinded fecal occult blood determinations with use of the 3 tests., Results: In the cross-sectional study, the HQT test detected 88% (37/42) of hemorrhagic upper GI tract lesions compared with 26% (11/42) detected by the HO test (P<.001) and 2% (1/42) by the HS test (P<.001). In the longitudinal study, all preingestion fecal occult blood test results were negative. After ingestion of 5 mL of blood, the HQT result became positive in 60% (6/10), and the HO and HS results remained negative (P=.03). After ingestion of 15 mL of blood, the HQT result became positive in all 10 cases, the HO result was positive in 6 (P=.12 vs HQT), and the HS result was positive in none (P=.002 vs HQT); all 3 stool samples collected after the 15-mL ingestion were positive in each of the 10 subjects by the HQT test but in only 1 subject by the HO test (P=.003)., Conclusion: The HQT test detects occult upper GI tract blood loss significantly more frequently than the HO or HS test.

Objectives: The dramatic growth of the Internet holds potential for use in survey distribution. Comparisons of electronic mail (e-mail) to traditional survey techniques are lacking. We compared standard mail, telephone, and e-mail modes of endoscopy satisfaction survey administration with respect to response rate, timeliness of response, response content, and cost-efficiency of responses., Methods: An endoscopy satisfaction questionnaire consisting of seven core items from the modified Group Health Association of America-9 survey was distributed to patients after routine outpatient endoscopy. Patients were randomized to receive the questionnaire by standard mail, telephone, or e-mail. Response rates and findings in the three groups were compared. The "nonresponders" to the standard mail and e-mail surveys were subsequently contacted by telephone to determine their level of satisfaction., Results: The phone survey response rate (90%) was higher than e-mail (70%) or standard mail (85%), although e-mail was the most cost-efficient mode of survey delivery. There was no significant difference in satisfaction scores among the three groups. Nonresponders were significantly more satisfied than "responders.", Conclusions: A survey technique utilizing e-mail with subsequent follow-up by telephone to nonresponders appears to be the most cost-efficient way to deliver a questionnaire. The satisfaction levels of the responders may underestimate the overall satisfaction of the population being surveyed.

Serological testing is an important tool in the diagnostic work-up of suspected celiac disease. Our aim was to apply a decision analysis model to compare the costs of serological testing versus small bowel biopsy in the diagnostic work-up of celiac disease. A cost-minimization approach was employed. A decision analysis model with three diagnostic arms was designed using Data Version 3.5: anti-gliadin antibody versus endomysial antibody versus small bowel biopsy. Response to gluten-free diet was considered diagnostic of celiac disease; lack of response prompted a small bowel biopsy to definitively exclude celiac disease. Baseline probabilities were varied using sensitivity analysis. Sensitivity analysis revealed that the endomysial antibody strategy was least costly, provided the prevalence of celiac disease was less than 42%; above this anti-gliadin antibody became the most economical option. In conclusion, initial screening with endomysial antibody is the least costly strategy for diagnosing celiac disease in a low risk population. Antigliadin antibody becomes the cheaper strategy for higher risk populations.

Objective: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) biopsy of nonperitumoral (NPT) lymph nodes (LN) can be helpful in preoperative staging of pancreatic head adenocarcinoma. The economic impact of this staging strategy has not yet been described. The aim of this study was to apply a decision analysis model to compare the costs of three approaches to the management of nonmetastatic pancreatic head adenocarcinoma: EUS FNA versus CT-guided FNA versus surgery. A cost minimization approach was employed, as viewed from the perspective of the payer., Methods: A decision analysis model was designed using DATA Version 3.5, taking the entry criteria as "resectable" pancreatic head adenocarcinoma as determined by helical CT. Detection of metastatic NPT LN on FNA signified unresectability and obviated the need for surgery. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional plus facility fees. The endpoint was cost of management per patient., Results: EUS FNA was the least costly strategy ($15,938) compared with CT FNA ($16,378) and surgery ($18,723). Sensitivity analysis revealed that EUS FNA remained the least costly option provided the frequency of NPT LN involvement was >4%; below this value, surgery became the least costly., Conclusions: EUS FNA is the least costly staging strategy in the workup of patients with nonmetastatic pancreatic head adenocarcinoma primarily because of confirmation of NPT LN involvement avoiding unnecessary surgery. These results support performing EUS in patients whose tumors are thought to be resectable on helical CT to enhance NPT LN assessment.

Fecal occult blood (FOB) tests have been evaluated primarily for the application of colorectal cancer screening. Less is known about the performance characteristics of FOB tests for the evaluation of iron deficiency, the most common other application. As most clinically important occult gastrointestinal bleeding arises from the proximal gut, it is critical that FOB tests target analytes that are stable during the enteric transit. Available data indicate that guaiac-type and immunochemical tests are insensitive for the detection of proximal gut bleeding, and their use may confound the evaluation of iron deficiency. In contrast, the heme porphyrin test is sensitive for both proximal and distal sources of occult gastrointestinal bleeding, and this FOB test would appear to be the most rational selection for use in patients with iron deficiency or anemia. Outcome data are needed to better assess the impact of FOB testing on algorithms for evaluation of iron deficiency.

The causes of chronic malabsorption may be categorized as decreased intestinal absorption, most commonly caused by celiac sprue; or maldigestion caused by pancreatic insufficiency. The initial step in the evaluation of these patients should include stool studies to confirm fat malabsorption. If fat malabsorption is confirmed, endoscopy with small-bowel biopsies and aspirates for bacterial culture usually follows. A normal endoscopic examination should lead to assessment of pancreatic function. In the setting of normal pancreatic function and the absence of bile acid deficiency, a barium radiograph of the small bowel should be made, looking for anatomical abnormalities. Celiac sprue is an intolerance to gluten caused by a combination of genetic, environmental, and immunologic factors. It classically causes malabsorption. However, it is likely that many patients who exhibit only minor manifestations of the disease go unrecognized and untreated. A presumed diagnosis of celiac sprue is confirmed after a clinical and endoscopic response to a gluten-free diet. Serological markers are available with high degrees of sensitivity and specificity, but duodenal biopsy remains the gold standard for diagnosis. A minority of patients are unresponsive to a gluten-free diet, and intestinal lymphoma should be suspected in these cases.

Myelodysplastic syndromes (MDS) may be associated with inflammatory bowel disease (IBD). We characterized the clinical features and outcomes of patients with concurrent IBD and MDS. Using a diagnostic index, we identified all patients with both IBD and MDS at our center between 1976 and 1997. We also calculated an incidence rate of MDS in IBD using population-based data from Olmsted County, Minnesota, between 1950 and 1993. Among approximately 15,000 IBD patients seen, 25 (approximately 0.17%) were diagnosed with MDS. Fourteen had Crohn's disease and 11 had ulcerative colitis. The median age at diagnosis of IBD, particularly Crohn's disease, was higher than expected. Median age at diagnosis of MDS was typical. All but one ulcerative colitis patient was diagnosed before the diagnosis of MDS, while one-half of Crohn's disease patients were diagnosed with both ailments simultaneously. Five patients who had been diagnosed with IBD first were persistently anemic for at least 1 year prior to diagnosis of MDS. Two Crohn's disease patients had received purine analogs in the past. Median follow-up after MDS diagnosis was 1 year. Seven patients died, including two who progressed to acute myeloid leukemia. The incidence rate of MDS in IBD based on Olmsted County data was 0 cases per 100,000 person-years (95% CI, 0-55.2). The seemingly high frequency of myelodysplastic syndromes in a large referral-based group of patients with IBD suggests an association; however, an increased risk of MDS was not observed in a small regional cohort of IBD patients. Patients with MDS are diagnosed with concurrent IBD at an age older than expected. Simultaneous diagnoses were made in one-half of Crohn's disease patients. MDS should be considered in the differential diagnosis of anemia in IBD patients.

Objective: Our aim was to retrospectively analyze the Mayo Clinic experience of descending perineum syndrome from 1987-1997., Methods: Clinical records were abstracted for demographic features, risk factors, results of anorectal and defecation tests, and a mailed questionnaire evaluated outcome and current symptoms., Results: All results are mean +/- SD. Clinically, 39 patients (38 women, one man), mean age 53+/-14 yr, presented with constipation (97%), incomplete rectal evacuation (92%), excessive straining (97%), digital rectal evacuation (38%), and fecal incontinence (15%). Laboratory tests showed anal sphincter resting pressure was 54+/-26 mm Hg, and squeeze pressure was 96+/-35 mm Hg; expulsion from the rectum of a 50-ml balloon required > 200 g added weight in 27%; perineal descent was 4.4+/-1 cm (normal < 4 cm) by scintigraphy. Scintigraphic evacuation, rectoanal angle change during defecation, and perineal descent were abnormal in 23%, 57%, and 78% of the patients, respectively. Associated features included female gender (96%), multiparity with vaginal delivery (55%), hysterectomy or cystocele/rectocele repair (74%). On follow-up, 64% responded; 17 of these 25 responders underwent pelvic floor retraining. At 2-yr median follow-up (range, 1-6 yr), 12 still experienced constipation or excessive straining; their perineal descent was greater than in patients who responded to retraining (p = 0.005)., Conclusions: Descending perineum syndrome is identifiable by clinical history and examination, and the most prevalent abnormality on testing is perineal descent > 4 cm; rectal balloon expulsion is an insensitive screening test for descending perineum syndrome. Pelvic floor retraining is a suboptimal treatment for this chronic disorder of rectal evacuation; the extent of perineal descent appears to be a useful predictor of response to retraining.

Lichen planus (LP) is an inflammatory papulosquamous disease which may affect the squamous epithelium of the esophagus. We reviewed six patients with esophageal lichen planus (ELP) seen at Mayo Clinic Rochester between 1984 and 1998. The presenting symptoms were dysphagia (in all six patients) and odynophagia (two patients). Cervical esophageal strictures were seen in four patients; average number of esophageal dilatations required was 15 (range, 10-18). Esophageal biopsies demonstrated the classical histologic findings of ELP in two patients, and a lymphocytic infiltrate in the other four. Concomitant lichen planus (LP) was seen at other sites in five patients: all five had oral LP preceeded by ELP symptoms in all five; three had genital LP preceeded by ELP symptoms in all three; two had dermal LP, preceeded by ELP symptoms in one. Proton pump inhibitors were tried unsuccessfully in all patients. Four patients were started on systemic steroid medication; three had resolution of symptoms within 1 month.