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ABSTRACT: The relative accuracy of helical CT and EUS for defining the local resectability of peripapillary malignancies is undefined.
Fifty-one patients with a peripapillary malignancy and no metastatic disease were prospectively evaluated with helical CT and EUS. Imaging results were compared with surgical staging, and a tumor was defined as resectable when there was no macroscopic or microscopic residual tumor.
Nine patients had surgically confirmed locally unresectable disease, which was accurately predicted by EUS in 6 patients (sensitivity 67%) and by helical CT in 3 patients (sensitivity 33%; p = 0.35). When only patients with complete EUS examinations were included, the sensitivities of EUS and helical CT for vascular invasion were 100% and 33% (p = 0.06), respectively. When all patients not undergoing surgery because of imaging evidence of locally unresectable disease were included, the sensitivities were 100% and 62.5% (p = 0.02), respectively. One of 15 patients with a tumor amenable to surgical resection was labeled as unresectable by EUS but subsequently had a local recurrence of the tumor. The specificities of EUS (93%) and helical CT (100%) were similar.
EUS is more sensitive than helical CT for detecting vascular invasion by peripapillary malignancies and should be added to staging protocols, particularly when findings on helical CT are equivocal.
Gastrointestinal Endoscopy 03/2001; 53(2):182-8. · 4.88 Impact Factor
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ABSTRACT: Ampullary tumors should be resected because of the high incidence of malignancy and the unreliability of preoperative endoscopic diagnosis. Controversy exists about whether to perform a transduodenal excision (TDE) or a pancreatoduodenectomy. This study evaluated the safety and long-term efficacy of TDE.
The records of 21 patients with a pathologic diagnosis of ampullary adenoma who underwent TDE were reviewed. Demographics, symptoms, pathologic findings, and outcomes were analyzed and long-term follow-up was ascertained.
Twenty-one patients (mean age, 61 years) underwent TDE. Final pathology showed adenoma in all patients including 1 (5%) with invasive cancer, 2 (9%) with microinvasive cancer, 6 (28%) with high-grade dysplasia, and 1 (5%) with low-grade dysplasia. The overall survival was 85% (mean follow-up of 38 months). One of 3 late deaths was likely related to disease progression. Sixteen of the 18 remaining patients (89%) had no evidence of tumor recurrence. One benign ampullary recurrence was successfully treated endoscopically. One additional patient developed an ampullary cancer and underwent pancreatoduodenectomy.
TDE of benign ampullary tumors, even those with varying grades of dysplasia, can be performed with acceptable morbidity and low rates of recurrence. Postoperative endoscopic surveillance is mandatory to identify recurrent tumors.
Surgery 11/2000; 128(4):694-701. · 3.10 Impact Factor
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M E Cannon,
S L Carpenter,
G H Elta,
T T Nostrant,
M L Kochman,
G G Ginsberg,
B Stotland,
E F Rosato,
J B Morris, F Eckhauser,
J M Scheiman
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ABSTRACT: Computerized tomography (CT), magnetic resonance imaging (MRI), and transabdominal ultrasound frequently fail to detect ampullary lesions. Endoscopic ultrasound (EUS) is a sensitive modality for detecting and staging ampullary tumors. Accurate staging may be affected by biliary stenting, which is frequently performed in these patients with obstructive jaundice. The present study assessed the accuracy of ampullary tumor staging with multiple imaging modalities in patients with and those without endobiliary stents.
Fifty consecutive patients with ampullary neoplasms from two endosonography centers were preoperatively staged by EUS plus CT (37 patients), MRI (13 patients), or angiography (10 patients) over a 3(1/2) year period. Twenty-five of the 50 patients had a transpapillary endobiliary stent present at the time of endosonographic examination. Accuracy of EUS, CT, MRI, and angiography was assessed with the TNM classification system and compared with surgical-pathologic staging. The influence of an endobiliary stent present at the time of EUS on staging accuracy of EUS was also evaluated.
EUS was more accurate than CT and MRI in the overall assessment of the T stage of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%). No significant difference in N stage accuracy was noted between the three imaging modalities (EUS 68%, CT 59%, MRI 77%). EUS T stage accuracy was reduced from 84% to 72% in the presence of a transpapillary endobiliary stent. This was most prominent in the understaging of T2/T3 carcinomas.
EUS is superior to CT and MRI in assessing T stage but not N stage of ampullary lesions. The presence of an endobiliary stent at EUS may result in underestimating the need for a Whipple resection because of tumor understaging.
Gastrointestinal Endoscopy 08/1999; 50(1):27-33. · 4.88 Impact Factor
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Pancreas 02/1991; 6 Suppl 1:S66-75. · 2.39 Impact Factor
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ABSTRACT: A review is given on the clinical features of carcinoid syndrome including symptomatology, diagnostics, biochemistry and treatment. We have reviewed the literature on current therapy of carcinoid patients with special emphasis on the use of the somatostatin analogue SMS 20-1995. In addition, we present data on the effects of SMS 201-995 on indices of a clinical, biochemical and tumor growth. Diarrhea is abolished or significantly reduced in 75% of patients, flushing improves in 100%, wheezing in 100% with a decrease in airways resistance, and in one patient myopathy has improved. Blood serotonin is notoriously resistant to intervention and urinary 5-HIAA will decrease in 75% of causes but subsequently rebounds in 38%. Tumors, in general, continue to grow, but this may be slowed or in rare cases tumor growth is arrested. In individual instances the tumor may even infarct, leading to spontaneous cure. Tumors secreting PP, ACTH and calcitonin may be particularly resistant to treatment, whereas VIP secreting tumors appear to be sensitive.
Acta Oncologica 02/1989; 28(3):389-402. · 3.33 Impact Factor
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ABSTRACT: In view of the characteristic intra-abdominal spread of carcinoma of the colon and rectum [1-3], the use of intraperitoneal chemotherapy may offer an alternative to intravenous or oral drug therapy and even radiation therapy for recurrent disease [4,5]. Several investigators have demonstrated that intraperitoneal drug administration may result in portal vein levels ten to 20 times higher than those observed in peripheral venous blood samples [6]. Traditionally, intraperitoneal chemotherapy has been administered through the Tenckhoff catheter system which was originally developed for peritoneal dialysis in patients with acute or chronic renal failure [7,8]. We report a case of Tenckhoff catheter erosion into the colon with subsequent fistulization developing 20 days after intra-operative placement for intraperitoneal or "belly bath" chemotherapy; this complication occurred in a patient with locally recurrent colorectal adenocarcinoma in whom pelvic peritoneal implants without hepatic metastases were identified at reoperation. This complication of the Tenckhoff catheter system has not previously been reported in the surgical literature.
Journal of Surgical Oncology 12/1984; 27(3):205-7. · 2.10 Impact Factor
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ABSTRACT: Eighty-two symptomatic patients with carcinoid tumors of the small intestine were examined and treated over a 20-year period. Common clinical features included weight loss, diarrhea, and symptoms of intermittent bowel obstruction; 25 patients (30%) exhibited the carcinoid syndrome. Multiple carcinoid tumors occurred in 23 patients (28%), and hepatic metastases were present in 30 (37%). All patients underwent operation. The overall mortality was 7%, and the cumulative five-year survival rate was 59%. Two factors influenced prognosis after operation: hepatic metastases and incomplete resection. Other variables, including the sex and age of the patient and the size of the primary tumor, were of no additional prognostic value. Wide resection of the tumor, including regional lymph nodes, is indicated, regardless of the size of the primary tumor.
Archives of Surgery 05/1983; 118(4):391-7. · 4.24 Impact Factor
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ABSTRACT: We performed endoscopic percutaneous gastrostomy (EPG) on 22 patients. All procedures were performed using local anesthesia with intravenous diazepam sedation. Formal laparotomy was not required. The mean patient age was 58 years (range, 21 to 83 years). Indications for EPG placement included neurologic disorders in 17 patients, head and neck tumors in four patients, and esophageal disease in one patient. The mean operative time for EPG was 27.5 minutes, with a range of 11 to 60 minutes. Two major complications, a gastrocolic fistula and an intraperitoneal gastric leak, occurred early in the series. The technique has been modified with no similar complications. Pneumoperitoneum after EPG was demonstrated in eight patients without sequelae. Ileus following EPG was not observed in any patient, and enteral feedings were uniformly resumed 48 hours after tube placement. Our early experience with EPG suggests that this technique is a safe, cost-effective, and time-saving alternative to traditional gastrostomy tube placement.
Archives of Surgery 05/1983; 118(4):449-53. · 4.24 Impact Factor
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ABSTRACT: The case of a patient with a constricting lesion of the hepatic flexure is presented. Radiographic and endoscopic findings
in this patient could not conclusively distinguish a benign from a malignant process. The patient eventually underwent operation,
at which time hemicolectomy and ileotransverse colostomy were performed. The final pathologic diagnosis of the resected lesion
was pseudolymphoma. The definition and significance of this diagnosis are discussed.
Diseases of the Colon & Rectum 02/1983; 26(1):68-72. · 3.13 Impact Factor
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Journal of Surgical Research 08/1981; 31(1):22-37. · 2.25 Impact Factor
