Gurpal Sandha

Does Onsite Cytotechnology Evaluation Improve the Accuracy of Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy?

BACKGROUND Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres. OBJECTIVE To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA. METHODS The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups. RESULTS A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001). CONCLUSION Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.

The impact of preoperative endoscopic ultrasound on the surgical management of pancreatic neuroendocrine tumours

BACKGROUND Endoscopic ultrasound (EUS) is accurate in diagnosing pancreatic neuroendocrine tumours (PNETs), but its impact on surgical management is unclear. OBJECTIVE To determine whether preoperative EUS findings altered the decision for, and extent of, surgery in patients with PNETs. METHODS A retrospective review of patients referred for EUS because of suspected PNETs was conducted. The diagnosis of PNETs was confirmed by EUS-guided fine needle aspiration cytology, where indicated, or by surgical histology. EUS findings were compared with computed tomography (CT) findings to determine whether there was an impact on the decision for surgical management. RESULTS Fourteen patients (10 women), with a mean age of 44 years, underwent EUS for suspected PNETs. PNETs were seen with CT in 10 of 13 patients (77%) and with EUS in 14 of 14 patients (100%). One obese patient could not fit into the CT scanner. This patient had five PNETs on EUS. Three patients with a normal CT scan were determined to have one or two PNETs on EUS. Three patients with one or two PNETs on CT were found to have five to eight PNETs on EUS. EUS altered the decision for possible surgical management in five of 14 patients (36%), either by identifying a PNET or by finding multiple and multifocal PNETs that were not visualized on CT scans. CONCLUSION EUS is useful in the preoperative assessment of PNETs by providing information that significantly influences the decision for surgical intervention or changes the extent of the planned surgery.

Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease.

Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.

The clinical impact and cost implications of endoscopic ultrasound on the use of endoscopic retrograde cholangiopancreatography in a Canadian university hospital

BACKGROUND Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic biliary imaging in choledocholithiasis. Evidence linking a decline in diagnostic ERCP with the introduction of EUS in clinical practice is limited. OBJECTIVE To assess the clinical impact and cost implications of a new EUS program on diagnostic ERCP at a tertiary referral centre. PATIENTS AND METHODS A retrospective review was performed of data collected during the first year of EUS at the University of Alberta Hospital (Edmonton, Alberta). Patients were referred for ERCP because of suspicion of choledocholithiasis based on clinical, biochemical and/or radiological parameters. If they were assessed to have an intermediate probability of choledocholithiasis, EUS was performed first. ERCP was performed if EUS suggested choledocholithiasis, whereas patients were clinically followed for six months if their EUS was normal. Cost data were assessed from a third-party payer perspective, and cost savings were expressed in terms of ERCP procedures avoided. RESULTS Over 12 months, 90 patients (63 female, mean age 58 years) underwent EUS for suspected biliary tract abnormalities. EUS suggested choledocholithiasis in 20 patients (22%), and this was confirmed by ERCP in 17 of the 20 patients. EUS was normal in 69 patients, and none underwent a subsequent ERCP during a six-month follow-up period. One patient had pancreatic cancer and did not undergo ERCP. The sensitivity and specificity of EUS for choledocholithiasis were 100% and 96%, respectively. A total of 440 ERCP procedures were performed over the same 12-month period, suggesting that EUS resulted in a 14% reduction in ERCP procedures (70 of 510). There were no complications of EUS. The cost of 90 EUS procedures was

Clinical application of a single-operator direct visualization system improves the diagnostic and therapeutic yield of endoscopic retrograde cholangiopancreatography

42,840, compared with

Acetylsalicylic acid use in patients with acute myocardial infarction and peptic ulcer bleeding

108,854 for 70 ERCP procedures. The cost savings for the first year were

4670 Endoscopic therapy in 207 bile leaks: validation of a treatment strategy.

66,014. CONCLUSION EUS appears to be accurate, safe and cost effective in diagnostic biliary imaging for suspected choledocholithiasis. The impact of EUS is the avoidance of ERCP in selected cases, thereby preventing the risk of complications. Diagnostic ERCP should not be performed in centres and regions with physicians trained in EUS.

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: A randomized controlled trial

BACKGROUND Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones. OBJECTIVE To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy. METHODS The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones. RESULTS Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis. CONCLUSION The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

Allopurinol to Prevent Pancreatitis After Endoscopic Retrograde Cholangiopancreatography (ERCP): A Randomized Placebo-Controlled Trial

BACKGROUND Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding. OBJECTIVE To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding. METHODS AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding. RESULTS A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included lowrisk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (+/- SD) blood transfusion requirement was 3.9+/-3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively. CONCLUSIONS The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.

The Clinical and Cost Impact of Endoscopic Ultrasound On ERCP in a Tertiary Referral Center

Background: Bile leak is the most common post-cholecystectomy complication with a variety of highly successful endoscopic therapies. In 1994, one author (MB) proposed a grading system to distinguish the severity of leak into low-grade (LG, leak identified only after intra-hepatic filling of contrast) or high-grade (HG, leak seen prior to intrahepatic filling). Subsequent therapy was based on this classification with sphincterotomy (BS) alone in LG and a stent (St) to bridge the leak in HG. Results: During a 10 yr period, 207 pts (mean age 54 yrs, 127 F) with bile leaks were referred to our unit for endoscopic management. Of these, 134 underwent laparoscopic cholecystectomy, 72 open cholecystectomy and 1 had spontaneous rupture of the bile duct. Pts presented 11.8 d (mean, range 1-50 d) after surgery. Modes of presentation were leakage of bile (drains 37%, T tube 11%, incisions 12%), pain (56%), jaundice (16%), fever (11%) and abdominal distension (7%). ERCP identified the site of leak in 204 pts: cystic duct stump in 159 (78%), duct of Luschka in 26 (13%) and other in 19 (9%). A review of the initial 85 pts classified leaks into LG and HG (see above). BS alone for LG leaks and St for HG leaks proved effective in 82/85 pts (96%). This strategy was then prospectively validated in the subsequent 122 pts. Results of the combined group (104 LG, 100 HG) are presented here. In the LG group, 75/104 pts had BS alone with improvement in 68 pts (91%). Further treatment was required in 7 pts (6 had St, 1 underwent surgery). St was the initial treatment in the remaining 29/104 pts. The reasons for this were: CBD stricture (11/29), coagulopathy preventing BS (8/29), severe sepsis (3/29), prior BS with inadequate drainage (2/29) and unclear indications (5/29). In the HG group, 97/100 pts had St. Persistent leakage necessitated re-stenting in 4/97 pts. Healing of the leak was documented on follow-up ERCP in all 97 pts. Three pts were not amenable to endoscopic therapy (2 with clips across CBD and 1 with incomplete cholecystectomy) and were referred for surgery. CBD stones were identified in 41 pts (28/104 LG, 13/100 HG) and extracted in all. The distribution of stone cases indicates no impact on severity of leak. Only 3 complications occured: 2 pts developed post-ERCP pancreatitis and 1 had duodenal perforation. There was no mortality. Conclusion: The use of this simple grading system for bile leaks and the relevent therapy has proven to be a useful tool for choice of endotherapy. The role of a stent without sphincterotomy or naso-biliary tube alone has not been evaluated in this series.