Torsten Kjærulf Pless

Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease.

Background: It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP). Methods: A cost‐effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget‐holders point of view. Results: MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty‐four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost‐effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK = 0.14 EUR). Conclusion: Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost‐effective strategy.

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 four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described.

Vacuum sealing and cooling as methods to preserve surgical specimens.

Recently, vacuum-based preservation of surgical specimens has been proposed as a safe alternative to formalin fixation at the surgical theater. The method seems feasible from a practical point of view, but no systematic study has examined the effect of vacuum sealing alone with respect to tissue preservation. In this study, we therefore subjected tissue samples from 5 different organs to treatments with and without vacuum sealing and cooling at 4°C to study the effect of vacuum sealing of surgical specimens with respect to tissue preservation and compare it with the effect of cooling. No preserving effect of vacuum sealing was observed with respect to cellular morphology, detection of immunohistochemical epitopes, or RNA integrity. In contrast, storage at 4°C was shown to preserve tissue to a higher degree than storage at room temperature for all included endpoints, independently of whether the tissue was subjected to vacuum sealing or not. We, therefore, conclude that vacuum sealing is not an alternative to cooling on ice.

Cost-effectiveness of different diagnostic strategies in patients with nonresectable upper gastrointestinal tract malignancies

AbstractBackground and methods: Using a simple model, this retrospective study evaluated the cost-effectiveness of different diagnostic strategies used for pretherapeutic detection of patients with disseminated or locally nonresectable upper gastrointestinal tract malignancies (UGIM). Of 162 consecutive UGIM patients referred for treatment, 73 (45%) had disseminated or locally nonresectable disease, and these patients were eligible for evaluation. Results: The noninvasive diagnostic strategies (computed tomography [CT] with ultrasonography [US] and endoscopic ultrasonography [EUS]) had a low procedure cost, but a diagnostic strategy based on CT with US or CT with US and laparoscopy was not cost-effective. The inclusion of endoscopic or laparoscopic ultrasonography seemed necessary to the provision of a cost-effective strategy because both techniques had a high diagnostic accuracy combined with a low cost. A change in diagnostic strategy from CT with US to CT with US and EUS resulted in a net saving regarding the cost of each additional nonresectable patient detected, but this strategy still required up to 20% futile explorative laparotomies. Conclusions: The combination of endoscopic and laparoscopic ultrasonography was cost-effective and had no complications in this study. We use this strategy as our standard in the pretherapeutic evaluation of UGIM patients.

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.

Giant ventral hernias and their repair. A 10 year follow up study.

A consecutive series of 32 repairs of massive incisional hernias have been followed up for a median of 45 months (range 8 months to 11 years). The reconstruction was based on the frontal leaf of the rectus abdominis and insertion of free fascia or pedicle flap from the tensor fascia lata muscle combined with transposition of the rectus muscle. Median size of the hernias was 20 x 17 cm (range 6-35 x 8-30). The incidence of risk factors for both recurrence as well as operative complications was high. During the median observation period of 45 months 9 hernias recurred, the main benefit of a successful reconstruction was relief of pain in the abdominal wall and the lower back. We conclude that the method is useful for the treatment of patients with large ventral hernias. Reduction of controllable recurrence risk factors is important, and the treatment requires substantial resources and expertise.

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.

Laparoscopic ultrasonography--a method for staging of upper gastrointestinal cancer.

Laparoscopic ultrasonography (LUS) is a method that can be useful in the staging of upper gastrointestinal cancer. Dedicated transducers are available, and preliminary studies have proposed indications for the use of LUS staging of hepatic, esophageal, gastric, and pancreatic cancer disease. In the staging and resectability assessment of upper gastrointestinal cancer LUS seems to provide important additional information thus avoiding futile laparotomies in non-resectable patients. This short review summarizes some of the most relevant references concerning the use of LUS in upper gastrointestinal tract cancer.