Search

Endoscopic ultrasound (EUS) has become the most accurate imaging modality for locoregional cancer staging of the gastrointestinal tract. Fine-needle aspiration (FNA) has added a new level of accuracy for EUS in nodal staging, with reported numbers in the 90% range for luminal and pancreaticobiliary disease. In addition, new non-gastrointestinal applications are being evaluated, such as the role of EUS-FNA for the staging of non-small-cell lung cancer and exploration of the posterior mediastinum. Furthermore, the same techniques that make safe tissue sampling possible are being explored for their use as interventional applications, such as EUS-guided celiac plexus neurolysis, fine-needle injection, EUS-guided pseudocyst drainage, and EUS-guided cholangiography and pancreatography. This review describes the current clinical status of EUS in gastrointestinal oncology, as well as future and novel indications and therapeutic strategies for this technology.

Background: No comparative information exists regarding clinical variations in EUS practice patterns among American and international endosonographers., Methods: Eligible attendees of the XIIIth International Symposium on EUS, October 4-6 2002, New York, New York, were asked to complete a 2-page survey questionnaire on clinical practice of EUS., Results: A total of 191 of 391 eligible attendees (48.9%) participated in the survey (110 from the United States, 81 from 30 different countries). The mean age of participants was 40.5 (10.6) years, and 171 (89.5%) were men. A total of 102 endosonographers (53.4%) were in academic practice. The majority (150, 78.5%) also performed ERCP. Seventy-eight (40.8%) had performed EUS for more than 5 years and 21 (11%) for less than 1 year. Only 36 (18.8%) had more than 6 months of dedicated hands-on EUS training, and more than a third of the respondents learned to perform EUS by observing others or they were self-taught. Compared with respondents from the United States, relatively fewer international respondents were performing open-access EUS, pancreatobiliary EUS procedures, and interventions such as EUS-guided FNA and celiac plexus neuralysis., Conclusions: This survey provides insight into the status of EUS as practiced in the United States and internationally. Although it appears that over the last decade EUS has become disseminated fairly uniformly on a global basis, a lack of consistent training standards and also inadequate opportunities for EUS training remain important areas of concern.

Background: The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS., Methods: A systematic literature review was performed by way of a PubMed search to find articles with the following terms: "biopsy-negative rectal adenomas," "preoperative ERUS diagnosis," and "surgical histopathology." Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data., Results: Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%., Conclusions: ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.

Background and Objective: Most insulinomas are solitary, benign and functional neuroendocrine pancreatic tumors which give rise to manifold symptoms. Their preoperative localization is often unclear, but the cure rate after their excision is very high. It was the aim of this study to analyse and evaluate our group of patients with regard to preoperative tumor localization and overall surgical results., Methods: Data were collected as part of prospective observations and retrospective evaluation of all patients treated for insulinoma between 1987 and 2003 at the department of visceral- thoracic- and vascular surgery at the Philipps University of Marburg. In all of them the diagnosis had been confirmed by a fasting test., Results: 40 patients with an insulinoma (22 females, 18 males; average age 52 years [range 12-87 years]) had been operated. The sensitivity of preoperative localization was 65% for endoscopic ultrasound, 33% for ultrasound, 33% for computed tomography, 15% for magnetic resonance imaging and 0% for somatostatin-receptor scintigraphy. But all insulinomas were identified intraoperatively by pancreas dissection and ultrasound (IOUS). 38 patients were completely cured by excision of the tumor., Conclusion: After positive biochemical and fasting tests and exclusion of diffuse abdominal metastases by transabdominal ultrasound, all patients should without further preoperative investigations undergo surgical excision of the insulinoma after bidigital palpation of the pancreas and IOUS. But if laparoscopic excision is planned, endoscopic ultrasound should be undertaken preoperatively.

Background: The aim of this study is to compare EUS and the others diagnostics tests in the correct localization of insulinomas., Methods: We prospectively investigated 30 patients with endoscopic ultrasound with a clinical diagnosis of insulinomas prior to surgical exploration. They were submitted to abdominal ultrasonography, spiral computed tomography and four patients were submitted to magnetic ressonance before EUS. Surgery was the gold standard for tumor localization., Results: Twenty-six tumors were benign (86.6%) and four were malign (13.4%). The median size tumors detected by EUS was 1.5 cm. The overall sensitivity of EUS in identifying insulinomas was 86.6% compared to 33% for CT, 40% to MRI and 90.9% to IUS. In 12 patients we were able to perform EUS-guided fine needle aspiration. Insulinoma was diagnosed in ten cytological specimens (83.3%). Tumors located in the head and body of the pancreas were seen by EUS in all patients, respectively but those located in the tail were diagnosed only in 55.5% of the cases., Conclusions: EUS has a high sensibility in the identification and localization of pancreatic insulinomas and should replace traditional methods of image when clinical suspicion is high.

Saline infusion sonohysterography consists of ultrasonographic imaging of the uterus and uterocervical cavity, using real-time ultrasonography during injection of sterile saline into the uterus. When properly performed, saline infusion sonohysterography can provide information about the uterus and endometrium. The most common indication for sonohysterography is abnormal uterine bleeding. sonohysterography should not be performed in a woman who is pregnant or could be pregnant or in a woman with a pelvic infection or unexplained pelvic tenderness. Physicians who perform or supervise diagnostic saline infusion sonohysterograpy should have training, experience, and demonstrated competence in gynecologic ultrasonography and saline infusion sonohysterography. Portions of this document were developed jointly with the American College of Radiology and the American Institute of Ultrasound in Medicine.

Aim: To investigate the clinical pathologic features of gastrointestinal leiomyoma and the diagnostic value of endoscopic ultrasonography (EUS) on gastrointestinal leiomyoma., Methods: A total of 106 patients with gastrointestinal leiomyoma diagnosed with EUS were studied. The location, size and layer origin of gastric and esophageal leiomyomas were analyzed and compared. The histological diagnosis of the resected specimens by endoscopy or surgery in some patients was compared with their results of EUS., Results: The majority of esophageal leiomyomas were located in the middle and lower part of the esophagus and their size was smaller than 1.0 cm, and 62.1 % of esophageal leiomyomas originated from the muscularis mucosae. Most of the gastric leiomyomas were located in the body and fundus of the stomach with a size of 1-2 cm. Almost all gastric leiomyomas (94.2 %) originated from the muscularis propria. The postoperative histological results of 54 patients treated by endoscopic resection or surgical excision were completely consistent with the preoperative diagnosis of EUS, and the diagnostic specificity of EUS to gastrointestinal leiomyoma was 94.7 %., Conclusion: The size and layer origin of esophageal leiomyomas are different from that of gastric leiomyomas. Being safe and accurate, EUS is the best method not only for gastrointestinal leiomyoma diagnosis but also for the follow-up of patients.

Background: Gastric mucus usually induces artefacts during endoscopic ultrasonography., Aim: To investigate the effectiveness of pre-medication with the proteolytic enzyme, pronase, before endoscopic ultrasonography., Methods: Out-patients scheduled for endoscopic ultrasonography were randomly assigned to oral pre-medication with the anti-foam agent, dimethylpolysiloxane, alone (treatment A; n = 29), with dimethylpolysiloxane plus sodium bicarbonate (treatment B; n = 29) or with dimethylpolysiloxane, sodium bicarbonate and pronase (treatment C; n = 29). All drinks were given about 10 min before the start of the procedure. After insertion of the endoscope, endoscopists recorded visibility scores before the procedure, imaging scores at endoscopic ultrasonography and the numbers of high-echo spots in the gastric cavity and on the gastric wall surface after the procedure., Results: Pre-medication with pronase (treatment C) significantly reduced (both at P < 0.05) the visibility score (score 4, 46%) in comparison with that obtained for pre-medication without pronase (10% for both treatments A and B). Treatment with pronase significantly reduced (both at P < 0.05) the endoscopic ultrasonography score in the gastric cavity (score 4, 34%) in comparison with that found for treatments A (7%) and B (0%). It also significantly reduced (P < 0.05) the endoscopic ultrasonography score on the gastric wall surface (score 4, 14%) in comparison with that observed for treatment A (3%). The numbers of high-echo spots in the gastric cavity and on the gastric wall surface were significantly less (both at P < 0.001) for pre-medication with pronase (treatment C) than for pre-medication with treatments A and B. There were no complications associated with the solutions., Conclusions: Pre-treatment with pronase reduced the artefacts during endoscopic ultrasonography.

Background and Objective: EUS-guided fine needle aspiration (EUS-FNA) has emerged as a highly accurate technique for detecting and classifying mediastinal and pancreatic lesions as well as abdominal and recently retroperitoneal masses with a minimum of risk for the patient., Patients and Methods: To objectify these statements, we evaluated the quality of 72 EUS-FNA specimens by cytologic and histopathologic classification, investigated their contamination with tissue from the needle pathway and observed puncture-related complications in a retrospective study of 44 EUS-FNA in 41 consecutive patients (56 +/- 14 years, m = 24, f = 17; 13 pancreatic, 9 adrenal, 6 abdominal and 13 mediastinal masses). EUS-FNA was performed using a PENTAX 32 UA endosonoscope (longitudinal 7.5 MHz sector array) in combination with a needle system type "Hancke-Vilmann"., Results: 16 vs. 11 of 34 histopathologic and 38 cytologic specimens were classified "excellent", 7 vs. 10 "sufficient", 7 vs. 13 "poor" and 4 vs. 4 "failed". Analysis of contamination with tissue from the needle pathway showed 4 vs. 2 specimens "highly", 3 vs. 14 "clearly", 8 vs. 19 "slightly" and 19 vs. 3 "not" contaminated. Specimens classified "excellent" were less contaminated (p = 0,037). EUS-FNA identified 35 benign and 24 malignant masses. Definite diagnosis failed in 13 specimens. One nonfatal complication occurred. EUS-FNA is an accurate (89 %) and low-risk procedure to examine primary undiagnosed mediastinal, pancreatic, intraabdominal and especially adrenal lesions in most of the cases. Contamination with tissue from the needle pathway seems to be a major predictive factor of poor specimen quality and failed diagnosis., Conclusion: EUS-FNA expands the diagnostic approach of mediastinal, abdominal, pancreatic and adrenal masses and provides accurate specimens for reaching new differential-diagnostic competence, especially in endocrinologic cases.

Purpose: Thickening of the gallbladder wall is often observed during abdominal sonographic examination in patients with acute hepatitis. However, there is rarely an opportunity for a histopathologic analysis of these structural changes. Endoscopic sonography (EUS) can accurately delineate the structure of the gallbladder wall and therefore may be useful for visualizing changes in the gallbladder wall in patients with acute hepatitis. Hence, we prospectively studied the ability of EUS to detect specific structural changes in the gallbladder wall in patients with acute hepatitis and examined the effect of high elevation of serum liver enzyme levels on the gallbladder wall., Methods: A study group of patients diagnosed with acute hepatitis who had gallbladder wall thickening and a control group of patients without acute hepatitis or gallbladder disease underwent EUS between May 1, 1999, and June 1, 2002. EUS was used to measure the thickness of the gallbladder wall and to visualize each of its layers. Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels of the patients with acute hepatitis were measured at the time of the EUS examination. Statistically significant differences were determined using an independent t test and the chi-squared test. A p value of less than 0.05 was considered statistically significant., Results: The acute hepatitis group comprised 28 men and 24 women with a mean age of 40.8 years. The control group comprised 25 men and 25 women with a mean age of 45.1 years. The mean gallbladder wall thickness +/- standard deviation in the acute hepatitis group (6.3 +/- 2.6 mm) was significantly greater than that in the control group (1.6 +/- 0.4 mm; p < 0.01). The mean thickness of the gallbladder wall for patients in whom both the AST and the ALT levels were 500 U/l or higher (7.0 +/- 2.6 mm) was significantly greater than that for patients with levels below 500 U/l (5.4 +/- 2.3 mm; p < 0.05). In the acute hepatitis group, EUS showed thickened, well-defined muscular and serosal layers of the gallbladder wall in 24 of the patients and a diffusely thickened gallbladder wall, in which each layer was ill defined, in the other 28 patients. The mean thickness of the gallbladder wall for patients with the pattern of ill-defined layers was significantly greater than that for the patients with the pattern of well-defined layers (p < 0.05). The pattern of ill-defined layers was more common among patients in whom the serum AST and ALT levels were at least 500 U/l than among patients with levels below 500 U/l (p < 0.05)., Conclusions: We propose that gallbladder wall thickening in patients with acute hepatitis is associated with prominent changes in the muscular and serosal layers. Patients with highly elevated serum liver enzyme levels are more likely to have gallbladder wall thickening and disruption of planes between the muscular and serosal layers than are patients with normal liver enzyme levels., (Copyright 2003 Wiley Periodicals, Inc.)

Study Objectives: To determine the test performance characteristics of CT scanning, positron emission tomography (PET) scanning, MRI, and endoscopic ultrasound (EUS) for staging the mediastinum, and to evaluate the accuracy of the clinical evaluation (ie, symptoms, physical findings, or routine blood test results) for predicting metastatic disease in patients in whom non-small cell lung cancer or small cell lung cancer is diagnosed., Design, Setting, and Participants: Systematic searches of MEDLINE, HealthStar, and Cochrane Library databases to July 2001, and of print bibliographies. Studies evaluating the staging results of CT scanning, PET scanning, MRI, or EUS, with either tissue histologic confirmation or long-term clinical follow-up, were included. The performance of the clinical evaluation was compared against the results of brain and abdominal CT scans and radionuclide bone scans., Measurement and Results: Pooled sensitivities and specificities for staging the mediastinum were as follows: for CT scanning: sensitivity, 0.57 (95% confidence interval [CI], 0.49 to 0.66); specificity, 0.82 (95% CI, 0.77 to 0.86); for PET scanning: sensitivity, 0.84 (95% CI, 0.78 to 0.89); specificity, 0.89 (95% CI, 0.83 to 0.93); and for EUS: sensitivity, 0.78 (95% CI, 0.61 to 0.89); specificity, 0.71 (95% CI, 0.56 to 0.82). For the evaluation of brain metastases, the summary estimate of the negative predictive value (NPV) of the clinical neurologic evaluation was 0.94 (95% CI, 0.91 to 0.96). For detecting adrenal and/or liver metastases, the summary NPV of the clinical evaluation was 0.95 (95% CI, 0.93 to 0.96), and for detecting bone metastases, it was 0.90 (95% CI, 0.86 to 0.93)., Conclusions: PET scanning is more accurate than CT scanning or EUS for detecting mediastinal metastases. The NPVs of the clinical evaluations for brain, abdominal, and bone metastases are > or = 90%, suggesting that routinely imaging asymptomatic lung cancer patients may not be necessary. However, more definitive prospective studies that better define the patient population and improved reference standards are necessary to more accurately assess the true NPV of the clinical evaluation.

A recently established clinical entity, intraductal papillary mucinous tumor (IPMT) of the pancreas embraces a spectrum of pathology ranging from benign to malignant disease. IPMT must be differentiated from other cystic neoplasms of the pancreas, as well as inflammatory cystic lesions. As the pancreas lies in close proximity to the gastric and duodenal walls, endoscopic ultrasonography (EUS) is ideally suited for imaging the pancreas. Additionally, EUS facilitates fine needle aspiration of pancreatic cysts and/or a dilated pancreatic duct for cytologic and tumor marker analysis. This article presents a brief history of IPMT, differential diagnosis, current imaging modalities, findings of cytologic and tumor marker analysis, prognosis, and treatment strategy. Special emphasis is dedicated to the role of EUS, as well as EUS with fine needle aspiration.

The role of EUS and EUS FNA in the evaluation of cystic pancreatic lesions is evolving. The detailed imaging provided by EUS and hence the ability to target the biopsy at suspicious areas within the pancreatic cystic lesion may prove to be invaluable. Improvements in EUS equipment will further secure the role of this technology when evaluating these patients.

From the data that are currently available, it appears that EUS can help to reliably distinguish between the majority of benign and neoplastic cystic lesions. In equivocal cases, or cases where a high suspicion for malignancy exists, the use of EUS-guided FNA for obtaining cytology and cystic fluid for analysis of various tumor markers, gives the best diagnostic yield. Occasionally, despite a complete evaluation of a cystic mass, the cyst type may not be determined. The decision regarding further management of these lesions should be based on a combination of factors including symptoms, cyst size, EUS morphology and the patient's overall medical condition. In the case of symptomatic, large, or suspicious lesions where the patient is a good surgical candidate, surgical resection should be performed. However, it becomes more difficult in the case of asymptomatic, small cystic lesions where the patient is not an optimal surgical candidate. In the latter scenario, applying EUS criteria for follow-up of small pancreatic cystic lesions as reported by Ikeda et al can help in the decision-making process. In this study, Ikeda et al reported on 31 patients with pancreatic cystic lesions of unknown etiology that were followed-up with semi-annual EUS exams over a 3-year period. In 87.1% of these lesions, the size was less than 2 cm. Their criteria included 1) a clear thin wall, 2) smooth contour, 3) round or oval shape, 4) no septum or nodules, 5) asymptomatic clinical presentation, and 6) no findings of chronic pancreatitis. The cystic lesions remained stable in 30/31 patients, and only one lesion increased in size. This lesion was resected and was found to be a retention cyst. We are optimistic that the role of EUS in the management of cystic neoplasms will continue to evolve and expand as future studies evaluate the clinical utility of imaging modalities for the optimal practice algorithm for managing these neoplasms.

This article discusses serous cystadenomas, the most common of the nonmucinous cystic lesions of the pancreas. These microcystic lesions were previously known as "glycogen-rich" cystadenomas because of the presence of glycogen within the cyst epithelium. A small percentage of these lesions are macrocystic, and it may be difficult to differentiate them from mucinous lesions; however, endoscopic ultrasound guided fine needle aspiration can provide diagnostic material from the cyst fluid. The second most common nonmucinous cyst, the islet cell tumor, is also discussed. These rare cystic tumors may or may not be accompanied by excess hormone production. The prognosis for the rare cystic tumors is good if they are resected successfully.

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

With the widespread use of advanced imaging techniques, cystic lesions of the pancreas are now diagnosed relatively frequently. The nature of these lesions vary from benign cysts (serous cvstadenoma) or an inflammatory process (pseudocyst), to premalignant (mucinous cystadenoma) or frankly malignant lesions (cystadenocarcinoma). Differentiation of various types of pancreatic cysts presents a diagnostic and therapeutic challenge, as clinical presentation may be vague. Laparoscopic ultrasonography (LAPUS), the biopsy of the cystic wall, and analysis of the cystic aspirate, although expensive and rather invasive procedures, significantly contribute to the differential diagnosis of pancreatic cystic lesions.

Background and Aims: After an initial period of excellent results with newly introduced imaging procedures, the accuracy of most imaging methods declines in later publications. This effect may be due to various methodological factors involved in the research. Using the example of endoscopic ultrasound (EUS), this study aimed to elucidate one of the factors possibly concerned--namely, the extent to which the examiners are adequately blinded., Methods: Well documented videotapes of EUS examinations of 101 patients with resected tumours of the oesophagus (n=32), stomach (n=33), or pancreas (n=36) were evaluated in three different ways: firstly, retrospective analysis under routine clinical conditions; secondly, evaluation of EUS videotapes in a strictly blinded fashion; and thirdly, evaluation of the same videotapes but with additional information from the video endoscopic appearance (oesophageal/gastric cancer) or from computed tomography results (pancreatic cancer). Histopathological T staging was used as the reference method., Results: The accuracy of EUS in T staging was 73% under routine conditions. This value fell significantly to 53% for the blinded evaluation but increased again to 62% for the unblinded evaluation. The sensitivity of staging T1/T2 tumours was 72% (routine EUS), 59% (blinded EUS), and 70% (unblinded EUS). The respective values for advanced tumours were 85%, 74%, and 72%., Conclusions: The accuracy of EUS for T staging in clinical practice appears to be lower than has previously been reported. In addition, blinded analysis produced significantly poorer results, which improved when another test was added. It may be speculated that better results with routine EUS obtained in a clinical setting are due to additional sources of information.

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 provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the use of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy., Participants: A non-Federal, non-advocate, 13-member panel representing the fields of gastroenterology, hepatology, clinical epidemiology, oncology, biostatistics, surgery, health services research, radiology, internal medicine, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300., Evidence: Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of ERCP research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience., Conference Process: Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government., Conclusions: In the diagnosis of choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and ERCP have comparable sensitivity and specificity. Patients undergoing cholecystectomy do not require ERCP preoperatively if there is low probability of having choledocholithiasis. Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones. ERCP with endoscopic sphincterotomy (ES) and stone removal is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. In patients with pancreatic or biliary cancer, the principal advantage of ERCP is palliation of biliary obstruction when surgery is not elected. In patients who have pancreatic or biliary cancer and who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. ERCP is the best means to diagnose ampullary cancers. ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts. Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures. With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.

Over the past two decades, endoscopic ultrasonography (EUS) has undergone a transition from being a novel imaging technique to a clinical diagnostic test that is necessary for the optimal management of gastrointestinal diseases. EUS has established itself as an important diagnostic modality, mainly for the detection and staging of gastrointestinal cancers. As EUS has become more widespread, research has gradually shifted towards studies that explore the effect of EUS on patient management and outcome. These outcome studies have examined the primary clinical applications of EUS, such as esophageal, gastric, pancreatic, and colorectal cancer staging, as well as the role of EUS in the diagnosis of inflammatory pancreatic diseases. Widespread use of EUS has recently led to studies that examine complications associated with the performance of the procedure. Endosonographers have continued efforts to define a clinical role for EUS in other gastrointestinal diseases, such as portal hypertension. EUS-guided fine-needle aspiration (FNA) is continuing to develop into a powerful diagnostic tool for the management of lung cancer and other mediastinal diseases. New applications for EUS-FNA are also emerging. Finally, investigators are continuing to explore the remaining frontier of EUS-guided therapy.

Objective: The aim of this study was to evaluate the ability of endoscopic ultrasound (EUS) alone to predict and differentiate malignant from benign cystic lesions of the pancreas., Methods: From January, 1995, to August, 1999, 98 cases of pancreatic cystic lesions were evaluated by EUS; all of these were originally imaged by cross-sectional modalities that were not diagnostic. Among these, surgical/pathological correlation was available in 48 patients. The original endosonographic images were reviewed by two endosonographers who were blinded to each other's interpretation and to the surgical and pathological interpretation. The EUS images were assessed for the presence or absence of the following characteristics: 1) wall, 2) solid component, 3) septae, 4) lymphadenopathy, and 5) number of cysts. These characteristics were then correlated with the surgical and pathological findings and were assessed to determine if any were predictors of the lesion being benign or malignant., Results: For reviewer A, the presence of a solid component by EUS was the only statistically significant predictor of malignancy (odds ratio = 4.73, 95% CI = 1.13-19.68, p = 0.03). However, 61% of patients with benign lesions were also interpreted by EUS to have a solid component. For reviewer B, none of the features were found to be significant predictors of a malignant lesion. When the results of both reviewers were combined, the presence of a solid component was not found to be a statistically significant predictor of malignancy (odds ratio = 1.046, 95% CI = 0.99-1.09, p = 0.07)., Conclusion: Endosonographic features cannot reliably differentiate between benign and malignant cystic lesions of the pancreas after a nondiagnostic cross-sectional modality.

The results of 54 consecutive saline infusion sonohysterograms (SIS) are presented. Sonohysterogram, in conjunction with Pipelle endometrial sampling, was found to be a reliable and accurate method of initial investigation of the endometrium and uterine cavity with good correlation with other methods of investigation. It was well tolerated in an outpatient setting, saved two out of three of the women from needing a hysteroscopy and curettage, and yielded information beyond that available from hysteroscopy and curettage.

Purpose: Although preoperative evaluation of early rectal cancers can be done by endoluminal sonography and by means of colonoscopic findings, it is still controversial whether endoluminal sonography can effectively discriminate mucosal from submucosal lesions. This study was performed to verify objective causes of errors in the evaluation of early rectal cancer (T0/1) using a review of videotaped endoluminal sonography images., Methods: Eighty-nine patients with suspected early rectal cancer on endoluminal sonography were included. Two different scanners with appropriate probes were used according to tumor location, i.e., transrectal ultrasonography was used to scan up to 8 cm of the rectum above the anal verge, whereas endoscopic ultrasonography was used to assess higher lesions. Endoluminal sonography images were correlated with histologic infiltration and were reevaluated carefully to identify sources of errors., Results: Sensitivity and specificity were 83.1 and 96.5 percent, respectively, for tumor staging, whereas sensitivity was very low compared with specificity (16.7 vs. 90.2 percent) for metastatic lymph nodes. Endoluminal sonography images showed irregularity of the underlying tumor border (P < 0.01) and hypoechoic blurring or cutoff of the inner and outer hypoechoic layers (P < 0.001), all of which closely correlated with histologic infiltration of tumor cells. Overstaging occurred more than twice as often as understaging in tumor reevaluation (14 vs. 5 occurrences). In contrast to tumors, lymph nodes showed a similar amount of both overstaging (four cases) and understaging (five cases). The sources of errors were summarized as five types: false instrumentation, interpretive errors, anatomic defects, imaging failure, and inevitable errors., Conclusions: Because false instrumentation, interpretive errors, and anatomic defects were considered preventable, 23 (82.1 percent) of the 28 errors might have been avoided. Therefore, a clear image by endoluminal sonography can effectively distinguish mucosal from submucosal lesions in early rectal cancer.

Endoscopic ultrasound (EUS) was developed in the 1970s specifically for the purpose of improved imaging of the pancreas. The close proximity of the pancreas to the gastric and duodenal lumen allows EUS to obtain high-resolution images, unobstructed by overlying bowel gas. EUS has fewer complications than endoscopic retrograde cholangiopancreatography (ERCP) and can detect features of chronic pancreatitis (CP) in the pancreatic parenchyma and duct that are not visible to any other imaging modality. Because of this high sensitivity, questions have arisen whether EUS is oversensitive, especially to ''early" CP. Without a definitive gold standard against which to measure EUS (or ERCP and function testing), it is currently not possible to know the true accuracy of these modalities for early CP. There is now an extensive body of literature suggesting that these early changes detected by EUS correlate with histologic changes of CP, and may predict response to pancreatic therapy. EUS is uniquely suited to performing endoscopic cyst drainage for pancreatic pseudocysts and for controlling the pain of CP by EUS-directed celiac plexus block. For endoscopic cystenterostomy, EUS allows the endoscopist to localize the cyst, determine if the cyst is drainable, and guide a needle and stent into the cyst in a single step. Several major questions remain. Can EUS features of CP guide other forms of therapy for CP such as enzyme replacement, sphincter of Oddi therapy, and stent therapy? Can the detection of early CP by EUS, and subsequent therapy, delay or prevent the onset of more severe CP? Can EUS detect early forms for dysplasia and malignancy in patients who are at high risk for pancreatic carcinoma? Do changes of "early" CP detected by EUS progress to more classic changes (calicification) over time?

Intraductal papillary-mucinous tumor (IPMT) is defined as a syndrome consisting of dilatation of the main pancreatic duct and/or branch ducts associated with mucin overproduction. The purpose was to evaluate the usefulness of different imaging techniques (CT, EUS, ERCP) for determination of tumor invasion and pancreatic extension. Diagnosis often is delayed because it is confused with chronic pancreatitis or cystic neoplasms of the pancreas. It is difficult to rule out invasive malignancy. MRCP can be an essential imaging modality because it is a non-invasive technique. Intraductal ultrasound or pancreatoscopy could become in the future an additional useful preoperative procedure. A high frequency of invasive carcinoma in patients operated for pancreatic IPMT is observed. Surgical resection should be extended until a normal tissue margin is encountered.

Background: Endoscopic ultrasound (EUS) is a minimally invasive, low risk method of diagnosis for chronic pancreatitis (CP). The degree to which endosonographers agree on the features and diagnosis of CP is unknown. For EUS to be considered an accurate test for CP, there must be good interobserver agreement., Methods: Forty-five pancreatic EUS examinations were videotaped by 3 experienced endosonographers. Examinations from 33 patients with suspected CP based on typical symptoms, as well as 12 control patients without suspected CP, were included. Eleven experienced endosonographers ("experts") who were blinded to clinical information independently evaluated all videotaped examinations for the presence of CP and the following 9 validated features of CP: echogenic foci, strands, lobularity, cysts, stones, duct dilatation, duct irregularity, hyperechoic duct margins, and visible side branches. The experts also ranked (most to least) which features they believed to be the most indicative of CP. Interobserver agreement was expressed as the kappa (kappa) statistic., Results: There was moderately good overall agreement for the final diagnosis of CP (kappa = 0.45). Agreement was good for individual features of duct dilatation (kappa = 0.6) and lobularity (kappa = 0.51) but poor for the other 7 features (kappa < 0.4). The expert panel had consensus or near consensus agreement (greater than 90%) on 206 of 450 (46%) individual EUS features including 22 of 45 diagnoses of CP. Agreement on the final diagnosis of CP was moderately good for those trained in third tier fellowships (kappa = 0.42 +/- 0.03) and those with more than 1100 lifetime pancreatic EUS examinations (kappa = 0.46 +/- 0.05). The presence of stones was regarded as the most predictive feature of CP by all endosonographers, followed by visible side branches, cysts, lobularity, irregular main pancreatic duct, hyperechoic foci, hyperechoic strands, main pancreatic duct dilatation, and main duct hyperechoic margins. The most common diagnostic criterion for the diagnosis of CP was the total number of features (median 4 or greater, range 3 or greater to 5 or greater)., Conclusions: EUS is a reliable method for the diagnosis of chronic pancreatitis with good interobserver agreement among experienced endosonographers. Agreement on the EUS diagnosis of chronic pancreatitis is comparable to other commonly used endoscopic procedures such as bleeding ulcer stigmata and computed tomography of the brain for stroke localization and better than the physical diagnosis of heart sounds.

Objective: Evaluate the feasibility and the value of hysterography, sonohysterography and hysteroscopy for investigation of abnormal uterine bleeding. Method. Longitudinal blind study of thirty-eight patients consulting for abnormal uterine bleeding during pre- and post menopause. All patients underwent an hysterography and transvaginal sonohysterography, in random order, followed by an hysteroscopy with histological sample. The results were compared with the histo-pathological examination that was used for reference diagnosis. Statistical study of sensitivity, specificity and Positive and Negative Predictive Value (PPV-NPV) of each investigation; rate of agreement by the coefficient of Kappa., Results: The hysterography offers a PPV of 83% and a NPV of 100%. The interpretation errors were associated with the simple mucous hypertrophy interpreted as "hyperplasy". The limits correspond to a contrast agent allergy. The sonohysterography had a VPP of 89% and a VPN of 100%. The false positive is due to the difficulties of distinguishing the clots from the polyps. The limits correspond to the difficulties of cervix catheterization (13%). As regards the hysteroscopy, the VPP was 81.5% and the VPN of 75%. The interpretation mistakes were associated with mucous hypertrophy and the hyperplasy., Conclusions: The most useful examination for abnormal uterine bleeding, in the first instance, is transvaginal sonography with saline instillation. A complement by Doppler study would probably make it possible to limit the false positives.

The treatment of rectal carcinoma is mainly determined by its local extension. Preoperative staging of rectal carcinoma was assessed by different methods: digital rectal examination, transrectal ultrasound, computed tomography, and magnetic resonance imaging. Digital rectal examination had a diagnostic accuracy between 68 and 83 per cent. The accuracy of transrectal ultrasound was between 67 and 93 per cent for tumor staging and between 62 and 88 per cent for lymph node staging. The accuracy of computed tomography was between 33 and 77 per cent for tumor staging and between 22 and 73 per cent for lymph node staging. The overall accuracy of magnetic resonance imaging with body coil was between 59 and 95 per cent, and between 39 and 95 per cent for lymph node staging. Use of an endorectal coil allows a slightly more consistent degree of accuracy, with tumor staging accuracy between 66 and 91 per cent, and lymph node staging accuracy between 72 and 79 percent. Preoperative radiation therapy makes transrectal ultrasound and computed tomography less effective as staging techniques.

Background: The role of endosonography in diagnosing and staging pancreatic adenocarcinoma is evolving. The aim of this review is to present recently published material comparing the performance of endosonography relative to other imaging modalities when evaluating a patient with a suspected or known carcinoma of the pancreas., Methods: Medline was searched using the terms 'endosonography' and 'pancreas neoplasms'. References from retrieved papers were reviewed to identify other reports. Emphasis was placed on peer-reviewed material published within the past 3 years that included comparison with other imaging modalities., Results: Despite advances in cross-sectional imaging modalities, endosonography remains the most sensitive and specific method to identify pancreatic mass lesions. Resectability determination of pancreatic carcinoma is best done with dual-phase helical CT, although endosonography may have slightly improved accuracy for lymph node assessment. Endosonography-guided fine-needle aspiration biopsy has high sensitivity (93%) and specificity (100%) when employed in patients with masses in whom pancreatic cancer is suspected but prior biopsies are negative., Conclusions: Endosonography can aid in diagnosing patients with pancreatic neoplasms through definitive inclusion or exclusion of a mass lesion as well as biopsy confirmation of malignancy. The role of endosonography in determination of resectability has been eclipsed by dual-phase helical CT.

Background: Gastrointestinal endoscopic ultrasound (EUS) has become an important imaging modality for the diagnosis and staging of gastrointestinal disorders. This study assessed current EUS practice, training, coding, and reimbursement in the United States., Methods: A direct mail survey was sent to members of the American Society for Gastrointestinal Endoscopy., Results: There were 115 American respondents. The median age was 39 years, 57% were in academic practice, and 84% performed endoscopic retrograde cholangiopancreatography. The median number of EUS procedures performed was 200. In the preceding year, the median number of upper EUS was 60, lower EUS 10, and EUS/fine-needle aspiration 3. The most common indication was evaluation of esophageal or gastric lesions. Forty-six (40%) trained an average of 0.4 advanced fellows in EUS during the prior year. Of endosonographers involved in training, 53% thought formal training was necessary, for a median of 6 months and 100 procedures; 82% did not know whether they were reimbursed for EUS. There was great variation in the use of current procedural terminology (CPT) codes for lower EUS and upper EUS/fine-needle aspiration., Conclusions: EUS in the United States in 1999 is performed mostly by young, academic, interventional endoscopists. Diagnostic upper EUS is most commonly performed. Few new endosonographers are being trained. There is great variability in CPT coding of lower EUS and EUS/fine-needle aspiration procedures.

Unlabelled: Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Digestive infiltration is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown with incomplete resection and sometimes repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectosigmoid infiltration but their usefulness in the preoperative staging is still to be evaluated. The aim of this work was to evaluate and compare both techniques in the preoperative detection of deep pelvic endometriosis, particularly digestive infiltration., Patients and Methods: From 1996 to 1998, 48 women with painful deep pelvic endometriosis had preoperative imaging exploration with endoscopic ultrasonography and MRI, and were operated on in order to attempt complete endometriosis resection. Patients were proposed for laparoscopic resection if endoscopic ultrasonography and/or MRI did not reveal digestive infiltration or for open resection if endoscopic ultrasonography and/or MRI were positive for digestive infiltration., Results: Endoscopic ultrasonography and/or MRI led to suspicion of digestive endometriosis in 16 patients. Surgical resection was performed in 12 and digestive wall invasion was histologically demonstrated. At final follow-up, all patients had a dramatic decrease of their symptoms. The remaining 4 patients refused digestive resection and had only laparoscopic gynecologic resection. Infiltration although not histologically proven was very likely both on operative findings and clinical evolution. Digestive infiltration was preoperatively excluded in the 32 other patients. All had a laparoscopic treatment without digestive resection and pain diminished in all patients. In the 12 patients group who had digestive resection, digestive infiltration was correctly diagnosed by endoscopic ultrasonography in all cases (no false negative) whereas MRI, even with the use of endocoil antenna, led to correct diagnosis in 8 out of 12 cases. When endoscopic ultrasonography was negative for digestive infiltration, laparoscopic resection of lesions at surgery appeared complete in all cases. For the 16 patients with presumed digestive infiltration, sensitivity of endoscopic ultrasonography and MRI was 100 and 75% respectively, with a 100% specificity in both cases. MRI appeared very accurate for the detection of ovarian endometriotic locations. MRI was more sensitive but less specific than endoscopic ultrasonography for the diagnosis of isolated endometriotic recto-vaginal septum and utero-sacral ligaments lesions., Conclusion: Endoscopic ultrasonography was the best technique for the diagnosis of digestive endometriotic infiltration, which complicates the therapeutic strategy. MRI, however, allows more complete staging of other pelvic endometriotic lesions.

Purpose: Transrectal ultrasound is the most accurate means of assessing the degree of invasion for rectal neoplasms. A learning curve for performing and interpreting these studies exists, but it is unknown how long or steep it is. We reviewed our initial results with transrectal ultrasound to determine our accuracy and to define the learning curve., Methods: All patients undergoing transrectal ultrasound during our initial 30 months of experience were included. Each patient was staged with transrectal ultrasound and, after resection, the histopathologic stage was compared with transrectal ultrasound staging. The accuracy of transrectal ultrasound was calculated at intervals as experience was gained., Results: A total of 42 examinations were performed on 41 neoplasms in 41 patients. Comparison between transrectal ultrasound and the pathologic stage could be made in 36 studies. Overall accuracy of degree of wall invasion was 78 percent. Overstaging occurred with eight neoplasms, and one lesion was understaged. Accuracy of transrectal ultrasound staging improved with time: 58 percent of the initial 12 studies were staged correctly compared with 87.5 percent accuracy in the remaining 24 examinations (P = 0.048)., Conclusion: A definite learning curve was apparent. We conclude that transrectal ultrasound is a relatively simple procedure to learn and, once a moderate degree of experience is gained, should be routinely incorporated into the evaluation of rectal neoplasms.

Endosonography (EUS) is a relative newcomer to the field of gastrointestinal endoscopy. Nevertheless, two prospective studies with similar results have shown that EUS leads to a change in management in roughly two-thirds of patients in whom it is performed, with many of these changes being to less invasive or less expensive management. Preliminary investigations on the use of catheter probes for performing EUS have shown similar effects. Specific investigations on the effect of EUS on the outcomes of patients with submucosal tumors, esophageal cancers, pancreatic cancers, and rectal cancers need to be performed. Selective studies have demonstrated EUS to be cost-effective for the management of submucosal tumors and ampullary tumors. The complication rate of EUS appears to be comparable to that of upper endoscopy. There is little or no information regarding training in EUS, practice variation, or affect of EUS on quality of life.

Background/aims: Endoscopic ultrasonography is expected to be useful for invasion depth staging of early gastric cancer. A prospective blind study of the staging characteristics of endoscopy and endoscopic ultrasonography for early gastric cancer was performed., Methods: Findings of endoscopy and endoscopic ultrasonography using a 20 MHz thin ultrasound probe were independently reviewed and the results of 52 early gastric cancer lesions analysed., Results: The overall accuracy rates in invasion depth staging of early gastric cancer were 63% for endoscopy and 71% for endoscopic ultrasonography. No statistically significant differences were observed in overall accuracy. Endoscopic ultrasonography tended to overstage, and lesions that were classified as mucosal cancer by endoscopic ultrasonography were very likely (95%) to be limited to the mucosa on histological examination. All 16 lesions staged as mucosal cancer independently but coincidentally by both methods were histologically limited to the mucosa., Conclusions: Endoscopic ultrasonography is expected to compensate for the understaging of lesions with submucosal invasion that are endoscopically staged as mucosal cancer.