-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: Endoscopic Mucosal Resection (EMR) has evolved as an effective technique to remove flat/sessile polyps in the gastrointestinal tract. Despite its relative safety, bleeding continues to be a major complication. Our objective was to identify patient/procedure characteristics which correlate with increased likelihood of bleeding, and thus anticipate the need for preventative therapy. METHODS: This was a retrospective, observational, descriptive study using a prospective EMR database, performed in a tertiary-care center. A total of 935 EMRs of various locations within the gastrointestinal tract were observed. The main outcome measurement was immediate bleeding (occurring during the procedure) and delayed bleeding (after completion of the procedure and up to 30 days after procedure). RESULTS: Early bleeding occurred during 5.3% (50/935) of procedures. In multivariate logistic regression analysis, esophageal EMR (OR 2.5, 95% CI 1.2 - 5, P = 0.0009), and increase in lesion size (OR 1.24, 95% CI 1.1 - 1.5, P = 0.003) were both associated with higher odds of early bleeding in EMR, while controlling for age, gender, and non-steriodal anti-inflammatory drug (NSAID)/clopidogrel use. Delayed bleeding occurred after 3.1% (n = 29) of the procedures. Of those, 86.2% (25/29) required hospital admission and endoscopic intervention to confirm and/or treat bleeding site. In multivariate logistic regression analysis, increased lesion size (OR 1.3, 95% CI 1.1 - 1.5, P = 0.004) was associated with higher incidence of delayed bleeding post-EMR. CONCLUSIONS: Bleeding during and after EMR appears to be uncommon in experienced hands. Larger lesions are at increased risk of immediate and delayed bleeding.
Journal of Digestive Diseases 10/2012; · 1.59 Impact Factor
-
Digestive and Liver Disease 11/2011; 44(1):16-7. · 3.05 Impact Factor
-
11/2011; , ISBN: 978-953-307-773-4
-
[show abstract]
[hide abstract]
ABSTRACT: Probe-based confocal laser endomicroscopy (pCLE) allows real-time in-vivo microscopic imaging of tissue. Narrow band imaging (NBI) can also classify colorectal lesions. Both systems may allow accurate optical diagnosis of small (6-9 mm) and diminutive (1-5 mm) polyps without histopathology. This study assesses the accuracy of pCLE and NBI for prediction of histology.
Participants underwent high-definition colonoscopy. The surface pit pattern of all polyps (1-9 mm) was determined in vivo using NBI. Confocal videos were obtained after administration of IV fluorescein. Recorded videos were subsequently analyzed offline, blinded to endoscopic characteristics, and histopathology. Confocal images were classified as neoplastic and non-neoplastic according to the Miami classification system.
A total of 130 polyps (58 neoplastic, 72 non-neoplastic, mean size 4.6 mm) from 65 patients were assessed. Assuming histopathology as gold standard, pCLE had higher sensitivity than NBI (86% vs. 64%, P=0.008), with lower specificity (78% vs. 92%, p=0.027) and similar overall accuracy (82% vs. 79%, P=0.59). When 65 high-confidence cases were analyzed (polyps diagnosed identically with pCLE and NBI and with high-quality confocal videos), sensitivity and specificity were 94 and 97%.
pCLE demonstrated higher sensitivity in predicting histology of small polyps compared with NBI, whereas NBI had higher specificity. When used in combination, the accuracy of pCLE and NBI was extremely high, approaching the accuracy of histopathology. Together, they may reduce the need for histological examination. However, further studies are warranted to evaluate the role of these techniques, especially in the population-based colon cancer screening.
The American Journal of Gastroenterology 11/2011; 107(2):231-9. · 7.28 Impact Factor
-
Anna M Buchner,
Victoria Gomez,
Michael G Heckman,
Muhammad W Shahid,
Sami Achem,
Kanwar R Gill,
Laith H Jamil,
Jamil Laith,
Michel Kahaleh,
Simon K Lo,
Michael Picco,
Douglas Riegert-Johnson,
Massimo Raimondo,
Daniela Sciemeca,
Herbert Wolfsen, Timothy Woodward,
Michael B Wallace
[show abstract]
[hide abstract]
ABSTRACT: Probe-based confocal laser endomicroscopy (pCLE) is an emerging tool for in vivo imaging of the GI tract that requires the endoscopist to interpret microscopic images. The learning curve for interpretation of pCLE images is unknown.
To examine the learning curve of correctly identifying benign and neoplastic colorectal lesions by using pCLE and to evaluate the learning curve of obtaining high-quality images.
Prospective, double-blind review of pCLE images of 76 colorectal lesions by using corresponding polypectomies as the reference standard. A training set of 20 images with known histology was first reviewed to standardize image interpretation, followed by blinded review of 76 unknown images.
Eleven endoscopists from 3 different endoscopy centers evaluated the images obtained by 1 endoscopist using the high-definition confocal probe.
Patients undergoing screening and surveillance colonoscopies.
Intravenous fluorescein pCLE imaging of colorectal lesions followed by polypectomies.
Accuracy of image interpretation with constructing learning curve for pCLE image interpretation and acquisition.
Of the 76 colorectal lesions, 51 (67%) were neoplastic and 25 (33%) were benign, based on histopathology. Accuracy for the overall group was 63% for lesions 1 to 20, 64% for lesions 21 to 40, 79% for lesions 41 to 60, and 86% for lesions 61 to 76. The ability to obtain high-quality images was stable over the 76 cases.
Small sample size and use of offline video sequences.
Accurate interpretation of pCLE images for predicting neoplastic lesions can be learned rapidly by a wide range of GI specialists. Furthermore, the ability to acquire high-quality pCLE images is also quickly learned.
Gastrointestinal endoscopy 03/2011; 73(3):556-60. · 6.71 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: EMR is being used to manage premalignant lesions of the GI tract. Lifting of the lesion is required to perform EMR. Earlier biopsy or snare may cause scarring and preclude adequate lifting.
We report our experience with a novel grasp-and-snare EMR technique that can be used when a good lifting is not achieved or the location of the lesion is challenging for standard EMR, such as in a fold.
Single-center case series.
Tertiary referral academic gastroenterology unit.
Patients referred for endoscopic treatment of flat gastrointestinal polyps.
Single-session EMR performed with a grasp-and-snare technique through a double-channel gastroscope or colonoscope.
Technical success, complication rates, and recurrence rates.
Seventeen patients with flat gastrointestinal polyps were referred: mean age 70 years, 11 (65%) male, polyp size 0.8 to 6 cm; 13 colonic, 2 duodenal, 1 gastric, and 1 esophageal EMR performed with grasp-and-snare technique in single sessions. Six polyps (35%) did not lift after injection of hydroxypropylmethylcellulose. Fourteen polyps (82%) were resected completely. Two complications occurred (12%): 1 bleeding treated medically and 1 perforation treated surgically. Residual disease at 1 year was 18%, but 8 patients (47%) had not yet had their 1-year follow-up.
Single-center, uncontrolled, not randomized. Limited follow-up.
The grasp-and-snare technique can be used to perform EMR with good outcomes and low complication rates in areas where poor lifting and accessibility are problems.
Gastrointestinal endoscopy 02/2011; 73(2):349-52. · 6.71 Impact Factor
-
Anna M Buchner,
Muhammad W Shahid,
Michael G Heckman,
Murli Krishna,
Marwan Ghabril,
Muhammad Hasan,
Julia E Crook,
Victoria Gomez,
Massimo Raimondo, Timothy Woodward,
Herbert C Wolfsen,
Michael B Wallace
[show abstract]
[hide abstract]
ABSTRACT: Probe-based confocal laser endomicroscopy (pCLE) allows in vivo imaging of tissue at micron resolution. Virtual chromoendoscopy systems, such as Fujinon intelligent color enhancement and narrow band imaging, also have potential to differentiate neoplastic colorectal lesions. The accuracy of these systems in clinical practice is, however, unknown. Our primary aim was to compare sensitivity and specificity of pCLE to virtual chromoendoscopy for classification of colorectal polyps using histopathology as a gold standard. A secondary aim was to compare sensitivity and specificity of pCLE to virtual chromoendoscopy using a modified gold standard that assumed that all polyps >/=10 mm had malignant potential and were considered neoplastic or high risk.
Patients underwent colonoscopy using high-resolution colonoscopes. The surface pit pattern was determined with NBI or FICE in all patients. Confocal images were recorded and subsequently analyzed offline, blinded to the endoscopic characteristics and histopathology. Each polyp was diagnosed as benign or neoplastic based on confocal features according to modified Mainz criteria.
A total of 119 polyps (81 neoplastic, 38 hyperplastic) from 75 patients was assessed. The pCLE had higher sensitivity compared to virtual chromoendoscopy when considering histopathology as gold standard (91% vs 77%; P = .010) and modified gold standard (88% vs 76%; P = .037). There was no statistically significant difference in specificity between pCLE and virtual chromoendoscopy when considering histopathology or modified gold standard.
Confocal endomicroscopy demonstrated higher sensitivity with similar specificity in classification of colorectal polyps. These new methods may replace the need for ex vivo histological confirmation of small polyps, but further studies are warranted.
Gastroenterology 11/2009; 138(3):834-42. · 11.68 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hyperechogenic pancreas (HP) suggestive of fatty replacement is a common finding during endoscopic ultrasound (EUS). Recent data have implicated pancreatic steatosis as a risk factor for pancreatitis and pancreatic malignancy. Hepatic steatosis has been linked to obesity, increased age, hypertriglyceridemia, hyperglycemia, and hyperinsulinemia. The objective of this study was to evaluate the effect of body mass index (BMI), hepatic steatosis, and other metabolic risk factors on HP seen on EUS.
Patients with HP were identified by a review of a structured EUS database. The degree of echogenicity was judged relative to the liver (or spleen if the liver is hyperechogenic) at a similar depth. Various demographic and metabolic risk factors were assessed. Chronic pancreatitis was excluded based on normal findings on prior imaging studies. Each case was age matched and sex matched to 1 control with a normal pancreas on EUS.
By multivariate logistic regression analysis, BMI, hepatic steatosis, and alcohol use in excess of 14 g/wk were highly associated with the presence of HP compared with controls (all P<0.002). Hepatic steatosis was the strongest predictor with an odds ratio of nearly 14-fold.
Hepatic steatosis, alcohol use, and increased BMI are predictors of HP, which can be a marker for steatosis.
Pancreas 06/2009; 38(6):672-5. · 2.39 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.
Lung cancer (Amsterdam, Netherlands) 06/2009; 67(3):366-71. · 3.14 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the natural course of <3-cm upper gastrointestinal subepithelial tumors by endoscopic ultrasound (EUS) and to determine the appropriate timing for EUS follow-up.
Subepithelial tumors (SETs) can range from benign lesions to tumors with malignant behavior or potential to become malignant such as gastrointestinal stromal tumors (GISTs). EUS is considered a valuable tool for their evaluation as it estimates the exact size and layer of origin, and also additional morphologic features that can suggest the diagnosis. For high surgical risk patients and when no worrisome EUS features are seen, EUS surveillance of subepithelial tumors is often used.
Fifty-one patients (mean age, 61.2+/-11.8 y; median, 63 y) with asymptomatic <3-cm SETs of second and fourth echolayer were followed for a mean period of 29.7 months (range, 3 to 84; median, 23 mo) in 3 tertiary care institutions. Evaluation included location, echolayer, tumor diameter, internal echo pattern, and outer margin of lesions by EUS. EUS was performed by using miniprobes, radial and linear echoendoscopes.
Follow-up revealed increase in size and/or change in echogenic features in 7/51 (13.7%) patients. Surgical follow-up was available for 3 of 7 of these patients. Two of the fourth layer SETs, which had both increase in size and change in echogenicity were found to be GISTs (+c-kit).
The majority of <3-cm SETs does not change during a median of 23 months. The change in echogenicity and increase in size may indicate a GIST.
Journal of clinical gastroenterology 03/2009; 43(8):723-6. · 2.21 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim of this study was to evaluate the technical feasibility of endosonographically-assisted transesophageal access for vagotomy, esophagomyotomy, and lymphadenectomy in a nonsurvival study with six porcine models in an animal laboratory with general anesthesia.
Saline/hydroxypropylmethylcellulose (HPMC) was injected into the submucosa with a subsequent biliary balloon dissection, creating a substantial submucosal space for a cap-fitted endoscope. A distal esophageal myotomy was performed after access into the thoracic cavity. Over the course of 6 pigs, esophagomyotomy (simulating a Heller myotomy), vagotomy, and lymphadenectomy were performed. The esophageal insertion/access site was sealed by the flap of mucosa.
Using a midesophageal entrance point, successful thoracic access and therapeutic interventions involving the esophagus and periesophageal structures were performed in 6 pigs.
The submucosal saline/HPMC tunneling technique allowed for successful access to the upper mediastinum through the esophagus with feasible therapeutic interventions.
Journal of Laparoendoscopic & Advanced Surgical Techniques 11/2008; 18(5):743-5. · 1.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Endoscopic mucosal resection (EMR) is a therapeutic modality that utilizes fluid to form a submucosal fluid cushion (SFC) for the treatment of early gastrointestinal neoplasia. The goal of this study was to determine the safety and efficacy in humans of EMR with hydroxypropyl methylcellulose (HPMC) as compared with historical controls of EMR performed with normal saline.
A retrospective cohort study presented data on EMR performed in 89 lesions in 88 patients was compared with 22 control EMRs performed with normal saline. Indications for EMR included known or suspected cancerous or precancerous lesions of the gastrointestinal tract. Efficacy of EMR was based on rates of complete excision and tumor recurrence.
EMR was performed in 89 lesions with HPMC-EMR used in 67 lesions and compared with 22 historical control lesions treated with saline EMR by the same five endoscopists. Lesion size and location were similar in both HPMC and saline groups. Complications were observed in six patients [5/67 (8%) HPMC and 1/22 (5%) saline, p > 0.2]. Long-term follow-up with repeat endoscopy was available on 43 lesions and identified 35/43 to be completely excised [20/25 (80%) HPMC-EMR and 15/18 (83%) saline EMR, p > 0.2]. Size of the lesion was not associated with success.
Both HPMC and normal saline are effective agents for creating a submucosal cushion for EMR. Larger randomized studies are needed to determine statistically significant differences in efficacy.
Surgical Endoscopy 07/2008; 22(11):2401-6. · 4.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Pancreatic cancer is one of the leading causes of cancer-related death in the USA. Recently, several centers have introduced portal and superior mesenteric vein resection and reconstruction during extended pancreatectomy, rendering the previously inoperable cases resectable.
The aim of this study is to confirm whether patients with locally advanced pancreatic cancer and mesenteric vascular invasion can be cured with extended pancreatectomy with vascular reconstruction (VR) and to compare their survival to patients treated with pancreatectomy without VR and those treated without resection (palliation).
Survival of 22 patients who underwent pancreatectomy with VR was compared with two control groups: 54 patients who underwent pancreatectomy without the need for VR and 28 patients whose pre-operative imaging suggested resectability but whose laparotomy indicated inoperability.
A slight survival benefit was noted in patients who did not require VR (33.5%) compared to those who did require VR [20%, p = 0.18], although not reaching statistical significance. Despite a low 15% three-year survival in patients treated palliatively, this was not statistically different compared to survival after resection with VR (P = 0.23). The presence of nodal metastasis was associated with worse survival (p = 0.006), and the use of adjuvant therapy was associated with better survival (p = 0.001).
Pancreatic cancers that require VR to completely resect the tumor have a similar survival to those not requiring VR. Long-term survival was achievable in approximately 1 out 5 patients requiring VR, although we were not able to demonstrate statistically improved survival compared to palliative care.
Journal of Gastrointestinal Surgery 10/2007; 11(9):1168-74. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Cystic neoplastic lesions of the pancreas (CNLP) are increasingly detected and are associated with a potential for malignant transformation. Diagnostic assessment of these lesions is often limited by the cystic nature and focality of neoplastic progression of these lesions. EUS-guided FNA (EUS-FNA) of cyst fluid and exfoliated cells is one of the most accurate methods of diagnosis but still has limited sensitivity. A new, through-the-needle cytologic brush system has recently been approved for use during EUS evaluation of cystic lesions of the pancreas.
To evaluate the cytologic yield and safety profile of the new cytobrush compared with conventional FNA in evaluating CNLP.
Ten consecutive patients with CNLP were included. All cysts were sampled by standard EUS-FNA (0.5 of cyst volume) followed by brush cytology, then by aspiration of the remaining fluid. Fluid samples were separately submitted (standard FNA and cytobrushings FNA) but were read by the same pathologist. Complications were assessed during the immediate postprocedure period (2-3 hours) and by a telephone call conducted approximately 30 days after the procedure to inquire about any new symptoms, including abdominal pain, melena, hematochezia, hematemesis, fever, nausea, and vomiting.
High-volume EUS referral center.
Ten consecutive patients with CNLP that measured at least 20 mm in maximal dimension were included.
Cellularity and presence of diagnostic cells on the FNA.
In 7 of 10 cases, the EchoBrush specimen was superior to FNA in terms of cellularity and detection of diagnostic cells. Two cases had complications: 1 major and 1 minor intracystic bleed. No infection or pancreatitis was observed.
The interpreting pathologist for the case was not blinded to the results of either of the samples. In addition, this pilot study represents only a single-center experience.
This study suggests that brush cytology specimens obtained at the time of EUS are superior to conventional FNA because of the higher yield of epithelial cells. It is unclear whether bleeding is more common after EchoBrush sampling; however, caution should be taken in patients who require anticoagulation until further data are available.
Gastrointestinal Endoscopy 06/2007; 65(6):894-8. · 4.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The focus of this chapter is to examine the role of endoscopic ultrasound (EUS) in the management of mediastinal lesions.
EUS, owing to its diagnostic accuracy, tissue sampling capability, low morbidity, and time and cost savings has become an
integral part of the multidisciplinary approach to the imaging and management of thoracic diseases. It is the intent of this
chapter to outline the benefit of EUS as an adjunct to modalities such as bronchoscopy, positron emission tomography (PET),
and computed tomography (CT) imaging in the evaluation of mediastinal diseases.
12/2005: pages 365-371;
-
[show abstract]
[hide abstract]
ABSTRACT: Background: Accurate staging of pancreatic cancer is essential for surgical planning, and identification of locally advanced and metastatic disease that is incurable by surgery. Advances in EUS, CT, and PET have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in non-surgical cases when chemo-radiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT-guided fine-needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false negative rate of nearly 20% makes this a less than ideal choice. The ability to position the EUS-transducer in direct proximity to the pancreas by means of stomach and the duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies.Methods: The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed.Results: EUS accuracy for tumor (T) staging ranges from approximately 78–94% and nodal (N) stage accuracy between 64 and 82%. EUS also enables FNA of lesions that are too small to be identified by CT or MRI, or too close to vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intralesional injection of antitumor therapy.Conclusions: EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer especially those too small to characterize by CT or MRI, and has the ability to obtain cytological confirmation.
Digestive Endoscopy 11/2004; 16(s2):S193 - S196. · 1.19 Impact Factor
