Henning Overgaard Nielsen

Impact of endoscopic ultrasonography (EUS) on surgical decision-making in upper gastrointestinal tract cancer : An international multicenter study

BackgroundEndoscopic ultrasonography (EUS) is an integrated part of the pretherapeutic evaluation program for patients with upper gastrointestinal (GI) tract cancer. Whether the clinical impact of EUS differs between surgeons from different countries is unknown. The same applies to the potential clinical influence of EUS misinterpretations. The aim of this study was to evaluate the interobserver agreement on predefined treatment strategies between surgeons from four different countries, with and without EUS, and to evaluate the clinical consequences of EUS misinterpretations.MethodsOne hundred patients with upper GI tract cancer were randomly selected from all upper GI tract cancer patients treated at Odense University Hospital between 1997 and 2000. Based on patient records and EUS database results, a case story was created with and without the EUS result for each patient. Four surgeons were asked to select the relevant treatment strategy in each case, at first without knowledge of the EUS and thereafter with the EUS result available. Interobserver agreement and impact of EUS misinterpretations were evaluated using the actual final treatment of each patient as reference.ResultsThree of four or all four surgeons agreed on the same treatment strategy for nearly 60% of the patients with and without the EUS results. Treatment decisions were changed in 34% based on the EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%). Interobserver agreement was relatively low, but overall EUS increased kappa values from 0.16 (“poor”) to 0.33 (“fair”), thus indicating increased overall agreement after the EUS results were available. EUS conclusion regarding stage or resectability was wrong in 17% of the cases, but only one serious event would have been the clinical result of EUS misinterpretations.ConclusionDespite being used in different ways by different surgeons, EUS did change patient management in one third of the cases. The impact of EUS misinterpretations seemed very low, and this study confirmed one of the strongest clinical possibilities of EUS, i.e., the ability to detect nonresectable cases. EUS is an important imaging modality for oncosurgeons from different countries.

Combined preoperative endoscopic and laparoscopic ultrasonography for prediction of R0 resection in upper gastrointestinal tract cancer

This study evaluated the ability of combined endoscopic and laparoscopic ultrasonography to predict R0 resection and avoid unnecessary surgery in patients with upper gastrointestinal tract cancer (UGIC).

Laparoscopic ultrasound-guided biopsy in upper gastrointestinal tract cancer patients

BackgroundNoninvasive pretherapeutic staging may be supplemented with laparoscopy and laparoscopic ultrasonography (LUS) in order to detect minute liver metastases, carcinosis or other signs of nonresectable or disseminated disease in patients with upper gastrointestinal tract cancer (UGIC). The aim of this study was to evaluate the use, potential clinical gain, and safety profile of LUS-guided biopsy in patients with UGIC.MethodsA prospective consecutive study on LUS-guided biopsy in patients referred with UGIC between May 2007 and May 2008 was carried out. Previous noninvasive imaging methods had found no signs of disseminated disease. Laparoscopic or LUS-guided biopsies were only performed if a malignant result would change patient management.ResultsTwo hundred and nine patients entered the study and, based on predefined biopsy indications, laparoscopy and LUS-guided biopsies changed patient management in a total of 27.3% (54/198) of the patients with a final malignant diagnosis. There were no complications. Liver and pancreas were the main target areas for LUS-guided biopsies, and more than half of the biopsies (55%) were taken from the primary tumor where other modalities had failed to obtain proof of malignancy. Twenty-six percent of biopsies were taken from a suspected metastatic lesion not seen before, whereas 19% were taken from previously suspected metastases where other imaging modalities had failed to obtain proof of malignancy.ConclusionLUS-guided biopsy is a safe procedure which in combination with laparoscopic biopsies had an impact on patient management in one-quarter of UGIC patients.

Combined endoscopic and laparoscopic ultrasound as preoperative assessment of patients with pancreatic cancer

BACKGROUND An accurate pre-therapeutic assessment of the resectability in pancreatic cancer patients is essential to reduce the number of futile surgical explorations. The aim of this study was to assess the combination of endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS) regarding the detection of patients with non-resectable tumours. PATIENTS AND METHODS From 2002 to 2004, 179 consecutive patients with pancreatic cancer referred for surgical treatment were eligible. Thirty-one (17%) patients were excluded due to co-morbidity and poor performance status. Two patients (1%) were excluded due to metastasis seen on CT scans prior to referral. Thus, 146 patients entered the study. Patients were first examined with EUS followed by LUS, if EUS found no signs of non-resectability. Only patients with tumours found to be resectable or possibly resectable at EUS and LUS were offered surgical treatment. Resectability criteria were defined prior to the study. RESULTS In all, 108 (74%) patients had non-resectable tumours by the pre-defined criteria. EUS identified 68 (63%) patients and LUS identified an additional 26 (24%) patients. Thus, a total of 94 (87%) patients were non-resectable at either EUS or LUS. Fifty-two (36%) patients underwent surgery. Six patients had surgical exploration and three patients had palliative surgery. Forty-three patients (29%) were resected with curative intention, of whom 38 (88%) had an R0 resection and 5 (12%) had a palliative resection. DISCUSSION The combination of EUS and LUS is accurate in identifying the non-resectable patients and has a high predictive value for complete resection.

A new method for three-dimensional laparoscopic ultrasound model reconstruction

BackgroundLaparoscopic ultrasound is an important modality in the staging of gastrointestinal tumors. Correct staging depends on good spatial understanding of the regional tumor infiltration. Three-dimensional (3D) models may facilitate the evaluation of tumor infiltration. The aim of the study was to perform a volumetric test and a clinical feasibility test of a new 3D method using standard laparoscopic ultrasound equipment.MethodsThree-dimensional models were reconstructed from a series of two-dimensional ultrasound images using either electromagnetic tracking or a new 3D method. The volumetric accuracy of the new method was tested ex vivo, and the clinical feasibility was tested on a small series of patients.ResultsBoth electromagnetic tracked reconstructions and the new 3D method gave good volumetric information with no significant difference. Clinical use of the new 3D method showed accurate models comparable to findings at surgery and pathology.ConclusionsThe use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes

BACKGROUND AND STUDY AIMS: No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes. PATIENTS AND METHODS: Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen. RESULTS: Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications. CONCLUSION: EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.

Potential impact of adding endoscopic ultrasound to standard imaging procedures in the preoperative assessment of resectability in patients with liver tumors.

Abstract Objective. The value of endoscopic ultrasonography (EUS) in patients with liver diseases is limitedly described. The aim of this study was to evaluate the potential impact of adding EUS to standard imaging procedures in the evaluation of resectability in patients with liver tumors. Material and methods. Patients who, based on the findings of CT and/or MRI, had been referred for curative resection of liver tumours were studied. Each patient underwent EUS before the final assessment of resectability, which was done by laparoscopic ultrasound or laparotomy. Results. Sixty-four patients were included. Intended curative resection was performed in 19 (30%) patients. Thirty-five (55%) patients were considered to have non-curative malignant disease. In 10 (15%) patients, the tumor was judged to be benign and surgery was not performed. There were no complications related to EUS. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS regarding prediction of non-resectability were 0.24, 0.94, 0.80 and 0.56 (tumor in right lobe), 0.50, 1.0, 1.0 and 0.75 (tumor in left lobe), and 0.60, 0.67, 0.86 and 0.33 (tumors in both lobes), respectively. Sixteen patients (25%) would have had changed their further management, if decision regarding non-resectability had been taken after EUS. Discussion. Addition of EUS to a standard imaging set-up based on CT and/or MRI would have changed the management in 25% of the patients otherwise scheduled for resection of suspected liver tumors.

The antral gastrin-producing cells in duodenal ulcer patients. A light microscopic and ultrastructural study during long-term, low dose treatment with cimetidine.

The antral mucosa has been examined in four duodenal ulcer patients before and during long-term, low dose treatment with cimetidine (given a total dose of between 472 g and 894 g). No convincing changes were found in the number or the volume of G cells. Signs of inactivity were demonstrated ultrastructurally, with small granules of intermediate type, a reduced amount of granular endoplasmatic reticulum and Golgi complex, mostly showing no signs of granulogenesis. The occurrence of bundles of cytoplasmic microfilaments, not observed before treatment and the reduced number of D cells may also be signs of inactivity. Hyperplasia and/or neoplasia were not seen in other antral endocrine cells.