M Canto

Prognosis of esophageal cancers preoperatively staged to be locally invasive (T4) by endoscopic ultrasound (EUS): a multicenter retrospective cohort study.

BACKGROUND Endosonography is a significant advance in the preoperative staging (TNM classification) of esophageal cancer. Its accuracy for evaluating depth of tumor invasion is over 80%. METHODS A multicenter retrospective cohort study of patients with esophageal carcinomas defined to be invasive (T4) by endosonography was performed to compare the survival of surgically and nonsurgically treated patients. Median survival time, overall mortality, and Kaplan-Meier survival curves were compared by treatment group. Univariate and Cox regression analysis were used to evaluate the effects of various prognostic factors and treatment on the risk of death. RESULTS A total of 79 patients were studied. The surgical group (Group I, n = 42) was significantly younger and had more distal tumors (adenocarcinomas) than the nonsurgical group (Group II, n = 37). Endosonography was significantly more accurate than CT scanning in identifying tumor invasion (87.5% versus 43.8%, respectively, p = .0002). Overall mortality rate was not significantly different between treatment groups; 59.5% of the surgical group and 64.9% of the nonsurgical group were dead at follow-up (p = 0.65). Similarly, the median survival times of Group I and Group II patients were similar (5.2 and 7.0 months, respectively, p = 0.50). Survival curves for the two groups were almost overlapping (log rank test, p = 0.84). Even after adjusting for age, histologic diagnosis, tumor location, and regional lymph node status, surgical treatment did not significantly influence survival (p = 0.24). CONCLUSIONS Endosonography accurately identifies patients with invasive T4 tumors who have a poor prognosis. This prognosis is independent of mode of therapy.

Push type enteroscopy is preferable to upper endoscopy in evaluation of iron deficiency anemia

PUSH TYPE ENTEROSCOPY IS PREFERABLE TO UPPER ENDOSCOPY IN EVALUATION OF IRON DEFICIENCY ANEMIA A Chak, G Cooper, M Canto, B Pollack, MV Sivak, Jr. Case Western Reserve University School of Medicine, Cleveland, Ohio. Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy (EGD) in patients with iron deficiency anemia. A source may not be identified even after the performance of these two diagnostic tests. AIM: To measure the additional diagnostic yield of examining the proximal jejunum of patients with iron deficiency anemia. METHODS: All patients with newly discovered iron deficiency anemia who had a) nondiagnostic colonoscopy; b) no symptoms referable to upper tract; and c) no EGD performed in previous 6 months were eligible. Standard EGD was initially performed with the Olympus SIF100 enteroscope, and was followed by gastric overtube assisted enteroscopy, Upper tract and jejunal sources of blood loss were noted. The small bowel was biopsied in patients without an identifiable bleeding source. RESULTS: Thirty one consecutive patients (13 men, mean age 71) who met study criteria between 2/93 and 8/96 were studied. Patients had a mean hematocrit of 29% (range, 18 to 46%) mean serum iron of 25.5 ug/dl, and a mean iron saturation of 7.8%. Eleven (35%) patients had a bleeding source that required only EGD for identification; 8 (26%) patients had a source only in the jejunum; 2 (6%) patients (1 with sprue) had a source in upper tract as well as jejunum. No source of blood loss was identified in 10 patients. No complications were noted, EGD examination required a mean of 7.8 minutes. On the average, examination of the jejunum required an additional 16.8 minutes. The endoscopist rated the entcroscopy as causing moderate discomfort in 6/31 (19%) patients, whereas the remainder had mild or no discomfort. Using Medicare reimbursement figures, a strategy of performing EGD first followed by PTE if EGD is nondiagnostic would have cost

Methylene blue staining of dysplastic and nondysplastic Barrett's esophagus: an in vivo and ex vivo study.

656 per patient, whereas the strategy of performing EGD with FFE as the initial test in all patients costs

Clinical applications of a new through-the-scope ultrasound probe: prospective comparison with an ultrasound endoscope

433 per patient. CONCLUSIONS: 1. Performance of PTE along with EGD increases the diagnostic yield from 41% to 67% when evaluating the upper tract of asymptomatic patients with iron deficiency anemia. 2. Performing EGD/PTE as the initial diagnostic test is a cost effective diagnostic approach in these patients.