Marc F. Catalano

Endosonographic features predictive of lymph node metastasis

Endosonographic features that are thought to characterize lymph node metastasis were evaluated in 100 patients with esophageal carcinoma. Subjects underwent preoperative endoscopic ultrasonography to assess depth of tumor invasion (T stage) and lymph node metastasis (N stage). Endosonographically imaged lymph nodes were evaluated according to the following parameters: size, shape, border demarcation, and central echo pattern. Sensitivity and specificity of endosonography in detecting lymph node metastasis were 89.1% and 91.7%, respectively, when stringent criteria were used. When lymph nodes were imaged endosonographically, regardless of the specific features, the likelihood of N1 disease, was 86%, whereas when no lymph nodes were imaged, the chance of N0 disease was 79%. Endosonographic features predictive of malignancy in increasing order of importance were echo-poor (hypoechoic) structure, sharply demarcated borders, rounded contour, and size greater than 10 mm. Collectively, the EUS features produced an additive effect with respect to accuracy in the prediction of malignant lymph node involvement; malignancy could be predicted with 100% accuracy when all four features were present. These results demonstrate that a careful and systematic approach to the endosonographic assessment of lymph node metastasis can improve staging accuracy.

Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis

BACKGROUND Chronic pancreatitis in its early stages may defy diagnosis despite existing diagnostic modalities. Endoscopic retrograde pancreatography (ERCP), secretin test, and conventional ultrasound are insensitive in detecting the early stages of chronic pancreatitis. The aim of this study was to determine whether endoscopic ultrasonography (EUS) high-resolution imaging allows for the detection of chronic pancreatitis as compared with clinical history, ERCP, and secretin test. METHODS Eighty consecutive patients with recurrent pancreatitis underwent ERCP, EUS, and secretin test. EUS evaluated parenchymal changes: echogenic foci (calcification), prominent interlobular septae (fibrosis), small cystic cavities (edema), lobulated outer gland margin (fibrosis/atrophy), and heterogeneous parenchyma; and ductal changes: dilation, irregularity, echogenic wall (fibrosis), side-branch ectasia, and echogenic foci (stones). EUS criteria for chronic pancreatitis included mild (1 to 2 features), moderate (3 to 5 features), and severe (more than 5 features). RESULTS Abnormal studies were EUS = 63, ERCP = 36, and secretin test = 25. Secretin test had 100% agreement with normal and severe chronic pancreatitis by EUS criteria, but agreement was poor for mild (13%) and moderate (50%) disease. Alternatively, the agreement between ERCP- and EUS-specific criteria was excellent for normal (100%), moderate (92%), and severe (100%) chronic pancreatitis and poor for mild (17%) disease. When the 2-test modality (ERCP and secretin test) was compared with EUS alone, no enhancement in agreement was seen. CONCLUSION Using the above criteria EUS may assist in the diagnosis of chronic pancreatitis not established by ERCP or secretin test. Excellent agreement can be expected between EUS and ERCP in the diagnosis of chronic pancreatitis with the exception of mild changes noted on EUS (kappa statistics = 0.82: 95% CI [0.70, 0.95]). Long-term follow-up of the patients with mild EUS changes will determine the validity of EUS in diagnosing the early stages of chronic pancreatitis.

Endoscopic management of adenoma of the major duodenal papilla

BACKGROUND It is well established that adenoma of the major duodenal papilla has a potential for malignant transformation. Standard treatment has been surgical (duodenotomy/local resection, pancreaticoduodenectomy). Endoscopic management is described, but there is no established consensus regarding the approach to papillectomy or the need for surveillance. This study describes endoscopic management and long-term follow-up of papillary tumors by 4 groups of expert pancreaticobiliary endoscopists. METHODS Consecutive patients with papillary tumors referred to 4 pancreaticobiliary endoscopy centers for evaluation for endoscopic papillectomy were reviewed. For each patient, an extensive questionnaire was completed, which included 19 preoperative and 15 postoperative data points. A total of 103 patients (53 women, 50 men, age range 24-93) who underwent attempted endoscopic resection were included. Of these, 72 had sporadic adenoma, and the remaining patients had familial adenomatous polyposis, including Gardners variant. Presenting symptoms were jaundice/cholangitis/pain (n=59), pancreatitis (n=18), and bleeding (n=12). Twenty-six patients were asymptomatic. RESULTS Endoscopic treatment was successful, long term, in 83 patients (80%) and failed (initial failure or recurrent tumor) in 20 (20%) patients. Success was significantly associated with older age (54.7 [16.6] vs. 46.6 [21.7] years; p=0.08) and smaller lesions (21.1 [8.3] vs. 29.7 [7.2] mm; p<0.0001). Success rate was higher for sporadic lesions compared with genetically determined lesions (63 of 72 [86%] vs. 20 of 31 [67%]; p=0.02). There were 10 initial failures, which was more common for sporadic lesions (7 of 10). The overall success rate for papillectomy was similar in patients who had adjuvant thermal ablation (81%) compared with those who did not (78%). However, recurrence (n=10) was more common in the former group (9 of 10, [90%]; p=0.22). Complications (n=10) included acute pancreatitis (n=5), bleeding (n=2), and late papillary stenosis (n=3). Acute pancreatitis was more common in patients who did not have pancreatic duct stents placed (17% vs. 3.3%). Papillary stenosis was more frequent without short-term pancreatic duct stent placement (15.4% vs. 1.1%), although the difference was not statistically significant, because this complication was infrequent. CONCLUSIONS Endoscopic treatment of papillary adenoma in selected patients appears to be highly successful. The majority can undergo complete resection after ERCP. In expert hands, complications are infrequent and may be avoided by routine placement of a pancreatic duct stent.

Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis

BACKGROUND Endoscopic treatment of pancreatic pseudocysts via cystenterostomy has been recognized as a successful treatment option in carefully selected patients. Pancreatic transpapillary stenting as an alternative treatment option in patients with pancreatic pseudocysts directly communicating with the main duct has received little consideration. The aim of the current study was to assess the safety and utility of transpapillary pancreatic endoprosthesis in the treatment of communicating pseudocysts. METHODS Twenty-one patients underwent placement of 33 transpapillary endoprostheses for the treatment of symptomatic pancreatic pseudocysts. All pseudocysts communicated with the main pancreatic duct and ranged in size from 3 to 9 cm (mean 6 cm). Eight patients had associated pancreatic duct strictures. RESULTS Stent placement was successful in all cases: 13 directly into the pseudocyst, 8 beyond the stricture but not into the pseudocyst. Initial resolution of pseudocysts was seen in 17 patients, with 16 patients free of pseudocyst recurrence at mean follow-up of 37 months. All patients with associated strictures were treated successfully. Factors predictive of success included presence of strictures, size of pseudocyst greater than or equal to 6 cm, location in the body of the pancreas, and duration of pseudocyst less than 6 months. Complications included one episode of mild pancreatitis. CONCLUSIONS Endoscopic treatment of symptomatic pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct stenting is a safe, effective modality and should be considered a first line therapy.

Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis

BACKGROUND The ability to identify common bile duct stones by noninvasive means in patients with acute biliary pancreatitis is limited. The aim of this study was to prospectively evaluate the ability of endosonography (EUS) to identify cholelithiasis and choledocholithiasis and predict disease severity in patients with nonalcoholic pancreatitis. METHODS EUS was performed immediately before endoscopic retrograde cholangiopancreatography (ERCP) by separate blinded examiners within 72 hours of admission. Gallbladder findings were compared between EUS and transabdominal ultrasonography (US). Using endoscopic extraction of a bile duct stone as the reference standard for choledocholithiasis, the diagnostic yield of EUS was compared with transabdominal US and ERCP. Features identified during endosonographic imaging of the pancreas were correlated with length of hospitalization. RESULTS Thirty-six patients were studied. EUS and transabdominal US were concordant in their interpretation of gallbladder findings in 92% of patients. The sensitivity of transabdominal US, EUS, and ERCP for identifying choledocholithiasis was 50%, 91%, and 92% and the accuracy was 83%, 97%, and 89%, respectively. Length of hospital stay was longer in patients with peripancreatic fluid (9.2 vs. 5.7 days, p < 0.1) and shorter in patients with coarse echo texture (2.6 vs. 7.2 days, p < 0.05) demonstrated on EUS. CONCLUSIONS EUS can reliably identify cholelithiasis and is more sensitive than transabdominal US in detecting choledocholithiasis in patients with biliary pancreatitis. EUS may be used early in the management of patients with acute pancreatitis to select those who would benefit from endoscopic stone extraction. The utility of EUS for predicting pancreatitis severity requires further investigation.

Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents

BACKGROUND Common bile duct stenosis occurs in up to 30% of patients with chronic pancreatitis. Most such stenoses are found incidentally during ERCP, but others manifest as obstructive jaundice, recurrent cholangitis, secondary biliary cirrhosis, or choledocholithiasis. Operative drainage has been the main treatment despite the potentially high morbidity in patients with chronic pancreatitis. Endoscopic biliary drainage with a single stent has been successful in the short term. The aim of this study was to determine the long-term benefit of a single stent vs. multiple simultaneous stents for treatment of patients with chronic pancreatitis and symptoms because of distal common bile duct stenosis. METHODS Twelve consecutive patients with chronic pancreatitis and common bile duct stenosis underwent endoscopic placement of multiple simultaneous stents and were followed prospectively (Group II). Results were compared with a group of 34 patients in whom a single stent was placed before the start of the present study (Group I). All 46 patients (35 men, 11 women; age range 30-71 years) had chronic pancreatitis and common bile duct stenosis, and presented with symptoms indicative of obstruction (abdominal pain, jaundice, elevated biochemical tests of liver function, acute pancreatitis, cholangitis). The 34 patients in Group I had single stent (10F, 7-9 cm) placement, with exchange at 3 to 6 month intervals (1-4 exchanges) over a mean of 21 months. The 12 patients in Group II underwent placement of multiple simultaneous stents at 3-month intervals (single 10F stents added sequentially) over a mean of 14 months. Mean follow-up was 4.2 years in Group I and 3.9 years for Group II. Factors assessed included symptoms, biochemical tests of liver function, diameter of common bile duct stenosis, and complications. RESULTS In Group I, (34 patients), a total of 162 single stent placement/exchanges were performed (mean 5/patient). In Group II (12 consecutive patients), 8 patients had 4 (10F) stents placed simultaneously, and 4 patients had 5 (10F) stents. At the end of the treatment period, near normalization of biochemical tests of liver function was observed for all patients in Group II, whereas only marginal benefit was noted for patients in Group I. Four patients in Group I had recurrent cholangitis (6 episodes), whereas no patient in Group II had post-procedure cholangitis. In the 12 patients with multiple stents, distal common bile duct stenosis diameter increased from a mean of 1.0 mm to 3.0 mm after treatment; no change in diameter was noted in patients treated with a single stent. CONCLUSIONS Distal common bile duct stenosis secondary to chronic pancreatitis can be treated long term by stent placement. Multiple, simultaneous stents appear to be superior to single stent placement and may provide good long-term benefit. The former resulted in near normalization of biochemical tests of liver function and an increase in distal common bile duct diameter. Multiple stent placement may obviate the need for surgical diversion procedures.

Endosonography in the evaluation of patients with Barrett's esophagus and high-grade dysplasia

Endosonography, which provides high-resolution images of the esophageal wall, could potentially detect carcinoma not visible endoscopically in patients with Barretts esophagus and high-grade dysplasia. We studied the ability of endosonography to detect early esophageal carcinoma in 9 patients with Barretts esophagus and high-grade dysplasia who were candidates for esophagectomy. Pre-operative endoscopy and biopsy revealed high-grade dysplasia without evidence of carcinoma in all patients. Pre-operative endosonographic evaluations were compared to the pathologic diagnoses of resected specimens. Post-operatively, 3 of the 9 patients were found to have intra-mucosal carcinoma. Endosonography identified a tumor in only 1 of these 3 patients and over-staged it as invasive carcinoma (T2, N1). In 2 of the 6 patients without intra-mucosal carcinoma, endosonography predicted invasive carcinoma (T2, N0). Endoscopy revealed mucosal nodularity in each of the 3 over-staged patients. We conclude that recommendation of the routine use of endosonography to determine the need for surgery in patients with Barretts esophagus and high-grade dysplasia would be premature, because the current generation of echo-endoscopes does not reliably differentiate between benign and malignant wall thickening.

Malignant esophageal strictures: Staging accuracy of endoscopic ultrasonography

The prognosis for patients with carcinoma of the esophagus remains poor despite aggressive combination therapies and radical surgical resections. Accuracy of staging esophageal carcinoma by endoscopic ultrasonography is unmatched by that of any other modality. Of patients with esophageal carcinoma, 20% to 36% present with high-grade malignant strictures that preclude passage of the echoendoscope. Aggressive wire-guided dilation followed by complete endoscopic ultrasonographic assessment or endosonography limited to the proximal aspect of the stricture has been used in staging these patients. Of 204 patients with esophageal carcinoma, 51 (25%) presented with high-grade malignant strictures, defined as stenosis precluding passage of the echoendoscope without prior dilation. Thirty-nine of the 51 patients were treated by esophageal resection. Twenty-one of these patients underwent preoperative staging using wire-guided dilation followed by endoscopic ultrasonography, whereas 18 underwent limited endosonographic staging. Correct preoperative assessment of depth of tumor invasion (T stage) was obtained in 33% (7 of 21) of the former group and 28% (5 of 18) of the latter group. Advanced tumor stage (stage III or IV) was present in 90% (35 of 39) of patients presenting with high-grade strictures, indicating a poor prognosis for those patients. The current study demonstrates that (1) approximately 25% of all patients with esophageal carcinoma present with high-grade stricutres that preclude passage of the echoendoscope without prior dilation, (2) the majority of patients with high-grade malignant strictures present with advanced disease (stage III or IV), and (3) because of the low accuracy of endoscopic ultrasonography in staging high-grade strictures, the need to subject such patients to invasive staging studies is questionable.

Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler

BACKGROUND The current standard treatment of bleeding esophageal varices is band ligation. Although endoscopic sclerotherapy has largely been supplanted by band ligation, there are still clinical situations in which injection methods are useful. Endoscopic ultrasound (EUS) may allow for a more complete evaluation of esophageal varices and perforating veins and may allow for more effective delivery of sclerosant. Our aim was to evaluate the use of color Doppler EUS-guided sclerotherapy for the obliteration of esophageal varices. METHODS Five patients with esophageal varices (Childs A = 1, B = 2, C = 2) underwent dynamic EUS-guided sclerotherapy with color flow Doppler. EUS sclerotherapy was performed using Varijet (2.5 mm catheter) injector needles and sodium morrhuate directed at the perforating vessels until flow was completely impeded (2 to 4 mL per injection site). Data collected included (1) sessions to obliteration, (2) episodes of recurrent bleeding, (3) complications, and (4) mortality. RESULTS Patients undergoing EUS-sclerotherapy required 2.2 sessions to achieve obliteration of varices. No patient had a recurrence of bleeding and no deaths occurred. One patient developed an esophageal stricture that responded to balloon dilation. CONCLUSIONS Dynamic EUS-guided sclerotherapy with color flow Doppler may be safely and effectively used for the treatment of esophageal varices. It allows for effective delivery of sclerosant with favorable outcomes. Prospective, multicenter, randomized trials are warranted.

Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial.

OBJECTIVES:We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet.METHODS:In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement.RESULTS:Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase ≥1. Resumption of solid food intake (GOOSS 2–3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2–3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients.CONCLUSIONS:Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2–3, the capacity for solid food intake endures until death or last follow-up.