Alan Savoy

Changing trends in endosonography : Linear imaging and tissue are increasingly the issue

The indications and uses of endoscopic ultrasound (EUS) are expanding. The role of EUS-guided fine needle aspiration (EUS-FNA) is considered an essential aspect of EUS practice. A significant change in the indications and technology used for EUS has occurred. This study was designed to compare the use of radial, linear, and miniprobe endosonography equipment during a 10-year period in a single, large, EUS practice. A retrospective review of an EUS experience at a single high-volume center was performed. In this single-center experience, there has been an increase in the volume of EUS and EUS-FNA. For luminal cancer-staging cases, the radial echoendoscope is the predominant scope used for examination and has not changed significantly. In contrast, for pancreaticobiliary and mediastinal indications, the use of the linear array echoendoscope alone has increased and currently is the preferred scope for examination (33% vs. 76%, P < 0.001; 46% vs. 96%, P < 0.001). In these cases requiring EUS-FNA, the use of the linear array scope alone has increased from 17% to 73%. In this single-center experience, EUS has shifted from an imaging technology to an image-guided biopsy and therapeutic technology. The use of the linear array EUS alone has increased, especially in the evaluation of pancreatobiliary and mediastinal disease and when fine-needle aspiration is performed.

The role of surveillance endoscopy and endosonography after endoscopic ablation of high-grade dysplasia and carcinoma of the esophagus

Barretts esophagus (BE) with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) is at risk of recurrence. The efficacy of endoscopic ultrasound (EUS) for surveillance after PDT is unknown. Our objective was to determine if EUS is superior to esophagogastroduodenoscopy (EGD) and/or CT scan for surveillance of BE neoplasia after PDT. The study was designed as a retrospective review with the setting as a tertiary referral center. Consecutive patients with BE with HGD or carcinoma in situ treated with PDT were followed with EUS, CT scan and EGD with jumbo biopsies every 1 cm at 3, 4, or 6-month intervals. Exclusion criteria was < 6 months of follow up and/or < 2 EUS procedures. Main outcome measurements were residual or recurrent disease discovered by any method. Results showed that 67/97 patients met the inclusion criteria (56 men and 11 women). Median follow-up was 16 months. Recurrent or residual adenocarcinoma (ACA) was detected in four patients during follow-up. EGD with random biopsies or targeted nodule biopsies detected three patients. EUS with endoscopic mucosal resection of the nodule confirmed T1 recurrence in one of these three. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA (fine needle aspiration) confirmed adenocarcinoma. There were two deaths, one related to disease progression and one unrelated. The rate of recurrent/persistent ACA after PDT was 4/67 = 6%. EUS did not detect disease when EGD and CT were normal. Limitations of this study include non-blinding of results and preferential status of non-invasive imaging (CT) over EUS. Our experience suggests that EUS has little role in the surveillance of these patients, unless discrete abnormalities are found on EGD or cross-sectional imaging.

Esophageal reflux in older patients with noncardiac chest pain

Purpose: Gastroesophageal Reflux (GER) has been commonly recognized in young and middle-aged patients with noncardiac chest pain (NCCP). GER prevalence rates are higher in older patients with typical presentation forms of the disease. There is paucity of information regarding the prevalence of GER in older patients with atypical forms of GER, i.e. NCCP. It is also unknown whether there are any differences in clinical presentations (heartburn/regurgitation) between young patients with NCCP and their elderly counterparts. HYPOTHESIS: GER is more prevalent in older than in younger patients with NCCP. AIM: Evaluate if there are differences in the prevalence rates of GER in our patient population with NCCP based on their age.