Background EUS is increasingly used in the diagnosis of chronic pancreatitis (CP). A number of publications in this field have used different EUS terminology, features, and criteria for CP, making it ...difficult to reproduce their findings and apply them in clinical practice. Moreover, traditional criteria such as the Cambridge classification for CP are arguably outdated and have lost their relevance. Objective Our purpose was to establish consensus-based criteria for EUS features of CP. Design Consensus study. Main Outcome Measurements Thirty-two internationally recognized endosonographers anonymously voted on terminology of EUS features, rank order, and category (major vs minor criteria). Consensus was defined as greater than two thirds agreement among participants. Results Major criteria for CP were (1) hyperechoic foci with shadowing and main pancreatic duct (PD) calculi and (2) lobularity with honeycombing. Minor criteria for CP were cysts, dilated ducts ≥3.5 mm, irregular PD contour, dilated side branches ≥1 mm, hyperechoic duct wall, strands, nonshadowing hyperechoic foci, and lobularity with noncontiguous lobules. Limitation Lack of broadly accepted reference standard. Conclusion In a complex disease such as CP that has no universally accepted reference standard, an EUS-based criterion for diagnosis can be determined by expert consensus opinion and the existing body of evidence. Here we present the new “Rosemont criteria” for the EUS diagnosis of CP.
Background Contemporary EUS-guided FNA techniques involve the use of a needle, with an air column within the lumen, with or without suction. We describe a novel technique with an aim to improve the ...quality of the aspirate. Objective To compare a novel “wet suction” technique (WEST) with the conventional FNA technique (CFNAT) of EUS-guided FNA using a 22-gauge FNA needle. Design Prospective, single-blind, and randomized trial. Setting Two large tertiary-care hospitals. Patients All consecutive adult patients presenting for EUS with possible FNA of solid lesions were offered the chance to participate in the study. Methods All lesions were sampled with the same needle by using alternating techniques. Patients were randomized to the WEST versus the CFNAT for the first pass. If the first pass was made with the WEST, the second pass was made with the CFNAT, and subsequent passes were made in an alternating manner by using the same sequence. All FNAs were performed using 22-gauge needles. Main Outcome Measurements Specimen adequacy, cellularity, and blood contamination of EUS-guided FNA aspirates graded on a predefined scale. Results The WEST yielded significantly higher cellularity in a cell block compared with the CFNAT, with a mean cellularity score of 1.82 ± 0.76 versus 1.45 ± 0.768 ( P < .0003). The WEST cell block resulted in a significantly better specimen adequacy of 85.5% versus 75.2% ( P < .035). There was no difference in the amount of blood contamination between the 2 techniques. Limitations Lack of cross check and grading by a second cytopathologist. Conclusion The novel WEST resulted in significantly better cellularity and specimen adequacy in cell blocks of EUS-guided FNA aspirate of solid lesions than the CFNAT.
Background Accurate assessment of pancreatic cystic neoplasms is imperative before selecting available treatment options, such as surgical resection, drainage, or conservative therapy. Available ...modalities, CT and magnetic resonance imaging, have been inconsistent in diagnosis. Reports involving EUS and cyst fluid analysis have been encouraging, including studies of EUS features and/or cyst fluid analysis, which may differentiate pancreatic cystic neoplasms. Objective To retrospectively determine cyst fluid characteristics that differentiate cystic neoplasms. Methods A total of 102 patients (60 women, 42 men; age, 23-76 years) presented for evaluation of pancreatic cystic neoplasm; 71 underwent surgical resection. Evaluation included (1) EUS features (reported elsewhere) and (2) cyst fluid analysis (carcinoembryonic antigen CEA, carbohydrate antigen 19-9 CA 19-9, amylase and lipase, viscosity VIS, mucin stain, and cytology). Exclusion criteria included the following: intraductal papillary mucinous tumor lesions, bloody cyst aspirate, neuroendocrine tumors, and patients without surgical histopathology. Results Seventy-one of 102 patients who underwent surgery presented the following histopathologic correlates: 23 pseudocysts (PC), 13 serous cystadenoma (SCyA), 21 mucinous cystadenoma (MCyA), and 14 mucinous cystadenocarcinoma (MCyA-CA). Cyst fluid analysis of these patients showed the following: VIS was lower in PC (mean, 1.3) and SCyA (1.27) when compared with MCyA (1.84) and MCyA-CA (1.9). All mucinous neoplasms had VIS >1.6, whereas only 2 nonmucinous neoplasms (MCN) had VIS = 1.6 (both PC). The CEA level was significantly higher in MCyA (adenoma 878 ng/mL, carcinoma 27,581 ng/mL) vs PC (189 ng/mL), and SCyA (121 •••). Amylase levels were higher in PC (7210 U/L) compared with cystic neoplasm (SCyA, 679 U/L; MCyA, 1605 U/L; MCyA-CA, 569 U/L). Conclusions Differential diagnosis of pancreatic cystic neoplasm is significantly enhanced by cyst fluid analysis. Elevated CEA (≥480 ng/mL) and VIS (>1.6) accurately predict MCN from SCyA and PC. Malignant from benign MCN can be differentiated by CEA levels ≥6000 ng/mL.
Background There is increasing demand for colonoscopy quality measures for procedures performed in ambulatory surgery centers. Benchmarks such as adenoma detection rate (ADR) are traditionally ...reported as static, one-dimensional point estimates at a provider or practice level. Objective To evaluate 6-year variability of ADRs for 370 gastroenterologists from across the nation. Design Observational cross-sectional analysis. Setting Collaborative quality metrics database from 2007 to 2012. Patients Patients who underwent colonoscopies in ambulatory surgery centers. Interventions Colonoscopy. Main Outcome Measurements The number of colonoscopies with an adenomatous polyp divided by the total number of colonoscopies (ADR-T), inclusive of indication and patient's sex. Results Data from 368,157 colonoscopies were included for analysis from 11 practices. Three practice sites (5, 8, and 10) were significantly above and 2 sites (3, 7) were significantly below mean ADR-T, with a 95% confidence interval (CI). High-performing sites had 9.0% higher ADR-T than sites belonging to the lowest quartile ( P < .001). The mean ADR-T remained stable for 9 of 11 sites. Regression analysis showed that the 2 practice sites where ADR-T varied had significant improvements in ADR-T during the 6-year period. For each, mean ADR-T improved an average of 0.5% per quarter for site 2 ( P = .001) and site 3 ( P = .021), which were average and low performers, respectively. Limitations Summary-level data, which does not allow cross-reference of variables at an individual level. Conclusion We found performance disparities among practice sites remaining relatively consistent over a 6-year period. The ability of certain sites to sustain their high-performance over 6 years suggests that further research is needed to identify key organizational processes and physician incentives that improve the quality of colonoscopy.
Background Obesity affects more than 30% of the U.S. population and is associated with the development of life-threatening complications. Numerous therapeutic approaches to the problem have been ...advocated, including low-calorie diets, anoretic drugs, behavior modifications, and exercise therapy. The only treatment proven to be effective in the long-term management of morbid obesity is surgical intervention. Complications of bariatric surgery include stomal stenosis and/or ulcer and stomal dilation (secondary to overeating). The latter complication can result in a gain of previously lost weight. Objective To determine the effect of endoscopic injection by using a sclerosant (sodium morrhuate) to induce stomal stenosis in patients who present with stomal dilatation complicated by weight gain. Design Bariatric patients with a large gastric stoma were treated with sodium morrhuate stomal injection. Diameters of the stoma were followed at repeat endoscopy. Weight loss at scheduled clinic visits were compared with pretherapy weights. Patients Twenty-eight patients (10 men, 18 women; age range, 27-58 years), after bariatric surgery with GI bypass, were referred with weight gain after initial weight loss. Weight gain was believed to be the result of a large gastric stoma. Interventions Treatment included injection of sodium morrhuate (1-2 mL circumferentially) surrounding the stoma. A total of 1 to 3 injection sessions were performed in an attempt to achieve a stoma diameter of 1.2 cm or smaller. Main Outcome Measurements Treatment success was defined as a decrease of stoma size to ≤12 mm and weight loss ≥75% of the weight the patient gained after establishing a steady state post bariatric surgery weight. Results A total of 2.3 injection sessions were performed. Successful endotherapy was achieved in 18 of 28 patients (64%). One patient developed symptoms of stomal stenosis, which required 2 separate balloon dilating sessions. No other complications were encountered. Limitations Retrospective case series. Conclusions Endoscopic injection of sodium morrhuate surrounding the dilated gastric stoma complicating bariatric surgery appears to be a successful, less-invasive therapeutic alternative to surgical revision.
Background Recently, the American College of Chest Physicians (ACCP) published evidence-based guidelines for the invasive staging of non-small-cell lung cancer (NSCLC), which shows the potential ...value of transesophageal sampling by EUS-guided FNA (EUS-FNA). The objective of the study was to determine the perceptions and the clinical practice of chest physicians regarding EUS-FNA as a staging modality for NSCLC. Methods We mailed a questionnaire to all members of the ACCP in Wisconsin. Results Seventy-one of 173 members (41%) responded. Chest physicians were more likely to perceive positron emission tomography, transbronchial needle aspiration, transthoracic needle aspiration, and mediastinoscopy to be able to make a difference in managing patients with NSCLC instead of EUS-FNA ( p = 0.01). Of the 40 chest physicians who believed that EUS-FNA can change the management of NSCLC, only 8 (20%) have sent a patient for EUS-FNA in the past year. Our findings may not necessarily reflect the opinions of chest physicians in other areas of the United States. Conclusions Many of the chest physicians surveyed do not believe EUS-FNA impacts the management of NSCLC. This limited awareness may represent a barrier to successful utilization of EUS-FNA in lung-cancer staging.
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