Anand Sahai

Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung

BACKGROUND Endoscopic ultrasound (EUS)-guided fine needle aspiration is a safe, cost-effective procedure that can confirm the presence of mediastinal lymph node metastases and mediastinal tumor invasion. We studied the accuracy of EUS in a large population of lung cancer patients with and without enlarged mediastinal lymph nodes on computed tomographic (CT) scan. METHODS From 1996 to 2000 all patients referred to our institution with lung tumors and no proven distant metastases were considered for EUS and surgical staging. Patients had endoscopic ultrasound with fine needle aspiration of abnormal appearing mediastinal lymph nodes and evaluation for mediastinal invasion of tumor (stage III or IV disease). Patients without confirmed stage III or IV disease had surgical staging. RESULTS Two hundred seventy-seven patients met the inclusion criteria, including 121 who had EUS. Endoscopic ultrasound and fine needle aspiration detected stage III or IV disease in 85 of 121 (70%). Among patients with enlarged lymph nodes on CT, 75 of 97 (77%) had stage III or IV disease detected by EUS. Among a small cohort of patients without enlarged mediastinal lymph nodes on CT, 10 of 24 (42%) had stage III or IV disease detected by EUS. For mediastinal lymph nodes only, the sensitivity of endoscopic ultrasound and CT was 87%. The specificity of EUS (100%) was superior to that of CT (32%) (p < 0.001). CONCLUSIONS Endoscopic ultrasound with fine needle aspiration identified and histologically confirmed mediastinal disease in more than two thirds of patients with carcinoma of the lung who have abnormal mediastinal CT scans. Although mediastinal disease was more likely in patients with an abnormal mediastinal CT, EUS also detected mediastinal disease in more than one third of patients with a normal mediastinal CT and deserves further study. Endoscopic ultrasound should be considered a first line method of presurgical evaluation of patients with tumors of the lung.

A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma

Tumor seeding along a needle tract is an established complication of percutaneous sampling of pancreatic masses under CT or transcutaneous US guidance. The risk of peritoneal carcinomatosis appears to be lower with EUS-guided FNA (EUS-FNA) compared with transcutaneous sampling methods. This is a potential advantage often cited for EUS-FNA because, to date, there is no case reported of tumor seeding from a pancreatic adenocarcinoma secondary to EUS-FNA. This report describes a case of apparent gastric-wall tumor seeding that occurred during EUS-FNA of a mass in the tail of the pancreas.

Randomized, Double-Blind, Controlled Trial of Early Endoscopic Ultrasound–Guided Celiac Plexus Neurolysis to Prevent Pain Progression in Patients With Newly Diagnosed, Painful, Inoperable Pancreatic Cancer

PURPOSE Celiac plexus neurolysis (CPN) is currently used as salvage therapy for morphine-resistant pancreatic cancer pain. Endoscopic ultrasound-guided CPN (EUS-CPN) can be performed early, at the time of EUS. We hypothesized that early EUS-CPN would reduce pain and morphine consumption, increase quality of life (QOL), and prolong survival. PATIENTS AND METHODS Patients were eligible if referred for EUS for suspected pancreatic cancer with related pain. If EUS and EUS-guided fine-needle aspiration cytology confirmed inoperable adenocarcinoma, patients were randomly assigned to early EUS-CPN or conventional pain management. Pain scores (7-point Likert scale), morphine equivalent consumption, and QOL scores (Digestive Disease Questionnaire-15) were assessed at 1 and 3 months. RESULTS Five hundred eighty eligible patients were seen between April 2006 and December 2008. Ninety-six patients were randomly assigned (48 patients per study arm). Pain relief was greater in the EUS-CPN group at 1 month and significantly greater at 3 months (difference in mean percent change in pain score = -28.9 [95% CI, -67.0 to 2.8], P = .09, and -60.7 [95% CI, -86.6 to -25.5], P = .01, respectively). Morphine consumption was similar in both groups at 1 month (difference in mean change in morphine consumption = -1.0 [95% CI, -47.7 to 49.2], P = .99), but tended toward lower consumption at 3 months in the neurolysis group (difference in mean change in morphine consumption = -49.5 [95% CI, -127.5 to 7.0], P = .10). There was no effect on QOL or survival. CONCLUSION Early EUS-CPN reduces pain and may moderate morphine consumption in patients with painful, inoperable pancreatic adenocarcinoma. EUS-CPN can be considered in all such patients at the time of diagnostic and staging EUS.

Central vs. Bilateral Endoscopic Ultrasound-Guided Celiac Plexus Block or Neurolysis: A Comparative Study of Short-Term Effectiveness

OBJECTIVES:Endoscopic ultrasound (EUS)-guided celiac plexus block/neurolysis (CPB/N) can be performed by injecting at the base (central) or on either side (bilateral) of the celiac axis. Central CPB/N is easier and possibly safer. Bilateral CPB/N is more difficult but may be more effective as it reaches more ganglia. The aim of this study was to compare the short-term safety and efficacy of central and bilateral CPB/N.METHODS:Consecutive patients referred for CPB/N to a quaternary EUS center were eligible for this study. Central CPB/N was used in the first half of the study period and bilateral CPB/N in the last half. The primary outcome was the percent reduction in visual analog pain scores at day 7.RESULTS:A total of 184 patients were eligible. Out of them, 24 (13%) were excluded for incomplete data. A total of 160 were left (71 central, 89 bilateral). The groups were similar for all cogent variables. Bilateral CPB/N was more effective than central CPB/N (mean percent pain reduction 70.4% (61.0–80.0) vs. 45.9% (32.7–57.4); P=0.0016). The only predictor of a>50% pain reduction was bilateral CPB/N (odds ratio 3.55, 1.72–7.34). Only one complication was noted: self-limited bleeding because of laceration of the adrenal artery following bilateral celiac plexus (CP) block in an anticoagulated patient.CONCLUSIONS:(i) Bilateral CPB/N is more effective than central CPB/N; (ii) bilateral CPB/N is safe, but on rare occasions can cause trauma to the left adrenal artery; it should therefore be avoided in patients with a bleeding diathesis.

EUS and chronic pancreatitis.

EUS provides unique information on pancreatic morphology, but the clinical value of EUS in managing patients with suspected or proven chronic pancreatitis remains controversial. The overriding concern appears to be that widespread application of EUS will result in overdiagnosis of chronic pancreatitis in the general population. Clearly, further work is required to clarify the clinical implications of minor pancreatic changes seen by EUS. However, this does not mean that EUS is of no value or should not be used at all for this indication. There are now several studies documenting good agreement between EUS and other diagnostic modalities that are accepted reference standards for the diagnosis of chronic pancreatitis, particularly endoscopic retrograde pancreatography (ERP). ERP may provide more information than less sensitive tests such as transcutaneous US and CT and may be a safe alternative to ERP and a more practical alternative to functional assays, which require duodenal intubation. However, there are practical issues that may affect its clinical applicability. Before using EUS for this indication, one should be aware of its limitations as well as the remaining unanswered questions regarding the clinical implications of EUS findings.

Comparison of endoscopic ultrasonography‐guided fine‐needle aspiration cytology results with and without the stylet in 3364 cases

Endoscopic ultrasound‐guided fine‐needle aspiration cytology (EUS‐FNA) is traditionally carried out with the stylet, as it is believed to prevent blockage or contamination of the needle by tissue coming from the gastrointestinal wall. However, this recommendation has not been demonstrated on an empirical basis. The aim of the present study was to compare the yield of EUS‐FNA in a very large series of patients with (S+) and without (S–) the stylet.

Celiac plexus neurolysis in the management of unresectable pancreatic cancer: When and how?

Pancreatic cancer is the second most common abdominal cancer in North America with an estimated 20% resectability at diagnosis, and overall 5-year survival of 5%. Pain is common in pancreatic cancer patients with 70%-80% suffering substantial pain. Celiac plexus neurolysis (CPN) is a technique that can potentially improve pain control in pancreatic cancer while preventing further escalation of opioid consumption. CPN is performed by injecting absolute alcohol into the celiac plexus neural network of ganglia. This review sets out to explore the current status of CPN in non-resectable pancreatic cancer. We will examine: (1) the efficacy and safety of percutaneous-CPN and endoscopic ultrasound guided-CPN; (2) specific technique modifications including bilateral (vs central) injections and celiac ganglia neurolysis; and (3) the issue of CPN timing, early at pancreatic cancer diagnosis vs traditional late use as salvage therapy.

An assessment of the use of costs and quality of life as outcomes in endoscopic research

BACKGROUND Costs and quality of life are increasingly important study outcomes. We quantitatively and qualitatively assessed their use in recent endoscopic research. METHODS All Medline-retrieved 1985 to 1995 published gastrointestinal endoscopic research using cost and/or quality of life as outcomes were analyzed. RESULTS Sixty-eight (1.2%) of an estimated 5568 publications discussed costs and/or quality of life as endoscopic outcomes (24 quality of life, 37 cost-effectiveness, 7 cost-benefit). Their use did not increase with time. Cost or quality of life was infrequently a primary study outcome. Twenty of 24 (83%) quality of life papers used an objective scale. However, of these, 15 of 20 (75%) used symptom indexes, performance scales, or other nonvalidated quality of life instruments. Two of 24 (8%) evaluated quality of life in nonmalignant disease. Eight of 40 (20%) papers claimed endoscopy was cost-effective, with no evidence of formal cost assessment. Ten of 32 (31%) substituted charges for costs. Of 21 papers reporting cost data, 4 (19%) specified cost type (e.g., direct vs other), 6 (29%) specified cost perspective, and 9 (43%) reported sensitivity analysis. Sixteen of 27 (59%) cost-effectiveness papers did not correlate costs with changes in a health outcome. CONCLUSIONS The overall cost and quality of life assessment in endoscopic research has been limited and must be improved. Accurate cost and quality of life assessment will require cooperation between gastroenterologists and experts in these fields.

Endoscopic ultrasonography for upper gastrointestinal submucosal lesions: a cost minimization analysis with an international perspective.

OBJECTIVES:Our prospective clinical study of prospectively compared physicians’ management of submucosal tumors (SMTs) with and without endoscopic ultrasound (EUS). It showed that EUS reduced further tests by more than 50%, but it is unclear whether it reduced the overall costs. The aim of this study was to determine whether EUS would reduce costs.METHODS:Based on the data from the clinical study, a decision analysis was created to compare the direct hospital costs for diagnosing SMTs with and without EUS. Cost data from Germany, Canada, Japan, France, and the United States were used. Costs were expressed as a ratio of the cost of esophagogastroduodenoscopy (EGD). Average cost ratios for each procedure were as follows (sensitivity analysis ranges are 95% CIs): EGD = 1; large particle biopsy (LPB) 0.75 (0.22–1.24); endoscopic ultrasound (EUS) 2.0 (1.22–2.79); abdominal ultrasound (US) 0.77 (0.31–1.24); computed tomography (CT) 1.79 (0.64–2.95); magnetic resonance imaging (MRI) 3.54 (1.28–5.79); and ERCP 3.45 (0.82–6.07).RESULTS:Initial inputs show the “no EUS” strategy is less costly when cost data for all countries are averaged (expected cost 2.13 vs 2.71, expressed as a ratio of the cost of EGD]) and for all countries individually except Germany. In descending order, overall management costs were most sensitive to the relative costs of CT and EUS, the cost of LPB, and to the probability of no further testing when the “no EUS” strategy is used. However, threshold analysis showed that changes in only one variable, the ratio of the cost of EUS compared to CT (the “EUS/CT ratio”), were able to shift the optimal strategy from “no EUS” to “EUS.” “EUS” becomes less costly only if the EUS/CT cost ratio is <0.85 (i.e., if the cost of EUS is <85% that of CT). If the potential for EUS to reduce severe complications caused by LPB of high risk lesions is incorporated, “EUS” is less costly if this risk is >2% (range 1–5%)CONCLUSION:When used to diagnose SMTs, EUS may reduce the need for further tests but not necessarily costs. For this indication, the relative cost of EUS compared with CT is what most limits its potential value as a cost-minimizing test. The costs, economic impact, and hence the relative appropriateness of EUS and other procedures may vary in different health care systems.

Randomized controlled trial comparing stylet‐free endoscopic ultrasound‐guided fine‐needle aspiration with 22‐G and 25‐G needles

Previous studies comparing endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) results with different gauge needles have all been carried out with the stylet in place and show no clear advantage to the larger 22‐G needle. Similar data for stylet‐free EUS‐FNA (SF‐EUS‐FNA) are unavailable. The aim of the present study was to determine whether diagnostic yield and specimen adequacy is superior with the 22‐G needle as compared to the 25‐G needle.