Background and Aims Eradication of sporadic nonampullary duodenal adenomas (SNADAs) is essential because of their high rate of malignant transformation. EMR techniques are the alternative to the ...traditional surgical treatments of SNADAs. There are very limited data on the safety and efficacy of cap-assisted EMR (C-EMR) in the treatment of SNADA. Methods The medical records of patients who underwent C-EMR for SNADAs between July 2002 and April 2013 were retrospectively reviewed. Eradication was defined as no residual adenoma on follow-up or en bloc resection on pathology. Recurrence was defined as finding adenoma after a negative follow-up. Results Fifty-nine C-EMR sessions were performed on 49 SNADAs (flat, 46; sessile, 3); 39 polyps were treated in piecemeal fashion and 10 polyps with en bloc resection. The polyp histology was tubular adenoma (63.3%) and tubulovillous adenoma (36.7%), with 16.3% of lesions showing high-grade dysplasia. Initial eradication rate was 90.5%; residual adenomas were successfully treated with repeat C-EMR/snare, resulting in 100% ultimate eradication rate without any recurrences (median follow-up of 17 months). The overall adverse events rate was 16.9%: intraprocedural bleeding (10.2%), delayed GI bleeding (5.1%), and perforation (1.7%). Among large polyps (≥15 mm), the initial and ultimate eradication rates were 87.9% and 100%, respectively, and the adverse event rate was 17%. Initial eradication rate for small polyps was higher than in large polyps (100% vs 87.9%, respectively; P = .02). Conclusion C-EMR is a highly efficient and safe method for the treatment of SNADAs. We recommend that endoscopists should learn C-EMR on esophageal, gastric, rectal, or left-sided colonic lesions before attempting C-EMR in the duodenum.
Abstract Background Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is the procedure of choice to investigate and sample pancreatic masses for the preoperative diagnosis of pancreatic ...ductal adenocarcinoma (PDAC). The role of18 fluoro-deoxyglucose positron emission tomography/computed tomography (PET/CT) in PDAC is debated. This study evaluates the role of EUS-FNA as compared to PET/CT in the preoperative evaluation of PDAC. Methods Preoperative evaluation by PET/CT and EUS-FNA was performed on 25 patients with pancreatic solid lesions, who underwent a subsequent Whipple procedure or partial pancreatic resection. Results This series included 19 PDACs and 6 non-PDACs including 1 metastatic breast ductal adenocarcinoma, 2 low grade neuroendocrine tumors, 2 chronic pancreatitis and 1 gastrointestinal tumor abutting the pancreas. EUS-FNA correctly diagnosed 18 of 19 PDACs, 1 metastatic breast ductal adenocarcinoma and all 5 of the other non-PDAC cases. One case of well differentiated PDAC was negative on EUS-FNA. PET/CT provided excellent size and was positive in 14 of 19 PDACs and the metastatic breast ductal adenocarcinoma. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for EUS-FNA in diagnosis of PDAC were 95%, 100%, 100%, 83% and 96%, respectively, while they were 75%, 100%, 100%, 50% and 80% for PET/CT, respectively. Conclusions Compared to PET/CT, EUS-FNA has a higher sensitivity and accuracy for preoperative diagnosis of PDAC. However, PET/CT provides excellent size, volume and stage information. A combination of both PET/CT and EUS will better help guide diagnosis and treatment of pancreatic adenocarcinoma.
Background The factors associated with maximizing the cytological adequacy of EUS-guided FNA (EUS-FNA) in pancreatic tumor evaluation are not well-known. Objective To examine associations of ...physician and procedural factors with the endpoint: the presence of an adequate cytological specimen found by using EUS-FNA in patients with pancreatic tumors and lymph nodes. Design Retrospective cohort study. Setting A U.S. tertiary care center. Patients Patients undergoing EUS-FNA of pancreatic masses and lymph nodes. Interventions Analysis of EUS-FNA procedures performed in our institution from 1997 to 2007. Main Outcome Measurements Associations were evaluated between the primary endpoint of cytological adequacy and factors including the endoscopist, needle gauge, the number of needle passes attempted, the pathologist, and the presence of an onsite cytotechnologist to confirm an adequate specimen. EUS-FNA adequacy was determined by a pathologist based on the presence of definite benign or malignant tissue. Results EUS-FNA was performed in 247 pancreatic masses and 276 lymph nodes. An adequate cytological sample was obtained in 240 (97%) pancreatic tumors (95% CI, 94%-99%) and 252 (91%) lymph nodes (95% CI, 87%-94%). For pancreatic tumors, there was no evidence of any associations between factors and cytological adequacy. For lymph nodes, cytological adequacy was improved when an onsite cytotechnologist was present (96% vs 84%, P = .002); no other factors showed statistically significant associations with cytological adequacy. Limitations Retrospective study, low power to detect associations. Conclusions The presence of an onsite cytotechnologist is an important factor in achieving successful EUS-FNA of suspicious lymph nodes in patients with pancreatic masses.
Background EUS is useful in determining mediastinal lymph node (LN) metastases in patients undergoing staging for lung cancer. However, FNA of LNs is often performed only if suspicious features are ...present. The utility of individual LN features in predicting malignant cytology remains unclear. Objective To evaluate the utility of EUS-determined LN features for predicting malignant cytology. Design Prospective observational study. Setting Two U.S. tertiary-care centers. Patients This study involved 425 patients with primary lung cancer who underwent EUS. Intervention All mediastinal LNs were described according to size, shape, echogenicity, and margin characteristics. FNA was performed on LNs with any features suggestive of malignancy. EUS-guided FNA cytology was classified as benign or abnormal (suspicious/malignant). The utility of LN features in predicting malignant cytology was determined and further analyzed by logistic regression, and a predictive model was established. Main Outcome Measurements Accuracy of individual LN features for predicting malignancy. Results EUS detected 836 LNs in 425 patients, and FNA was obtained in 698 patients. On multivariable analysis, only round shape, a short axis of >8.3 mm, and sharp margins were predictive of malignant cytology. According to the predictive model, the calculated probability of having malignancy is less than 4% (95% confidence interval CI, 0.022-0.064) when none of the LN features are present and 63% (95% CI, 51%-72.2%) when all features were seen. Limitations No surgical histology as the criterion standard. Conclusion Among patients with lung cancer, EUS features of round shape, sharp margins, and short axis of >8.3 mm are significant predictors of malignancy. The probability of malignancy is low when none of the features are present.
Background An American Society for Gastrointestinal Endoscopy–American College of Gastroenterology (ASGE-ACG) task force recently developed quality indicators for the preprocedure, intraprocedure, ...and postprocedure phases of each endoscopic procedure. Benchmark rates and clinical significance of compliance have not been determined. Objectives To establish baseline compliance rates to the preprocedure and intraprocedure quality indicators in our EUS cases, identify indicators with the lowest compliance rates, and establish change in compliance rates with a targeted performance improvement plan. Methods We measured baseline compliance to each of the preprocedure and intraprocedure EUS quality indicators in the EUS procedures performed at Mayo Clinic Jacksonville from March 1996 through August 2006. We developed a performance improvement plan that targeted the 4 indicators with the lowest compliance over the entire time period. Compliance rates in the year after plan implementation were compared with those from January 2004 to August 2006, when adjusting for endoscopist and direct access. Results We demonstrated areas of high quality as well as areas for improvement in compliance with the ASGE-ACG quality metrics in a large cohort of EUS cases. We achieved improvement in all 4 areas targeted for quality improvement, statistically significant at the 5% level for two of the quality indicators. Limitations Limitations included our retrospective design and the use of unstructured procedure dictations that may limit application of our results. It is also unclear whether compliance was truly synonymous with performance. Conclusions We established reference levels of compliance rate within our practice and showed that a targeted performance improvement plan that consisted of awareness, individual accountability, and documentation can result in improvement.
As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the ...parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.
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