C P Hovendal

Odense University Hospital, Odense, South Denmark, Denmark

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Publications (50)109.28 Total impact

  • M H Larsen · C Fristrup · T P Hansen · C P Hovendal · M B Mortensen
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    ABSTRACT: Accurate lymph node staging is essential for the selection of an optimal treatment in patients with upper gastrointestinal cancer. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are considered to be the most accurate method for locoregional staging. Endoscopic sonoelastography (ESE) assesses the elasticity of lymph nodes and has been used to differentiate lymph nodes with promising results. The aim of this study was to evaluate the use of EUS, EUS - FNA, ESE, and ESE-strain ratio using histology as the gold standard. Patients with upper gastrointestinal cancer who were referred for EUS examination were enrolled if surgical treatment was planned and the patient had a lymph node that was accessible for EUS - FNA and EUS-guided fine-needle marking (FNM). The lymph node was classified using EUS, ESE, and ESE-strain ratio. Finally, EUS - FNA and EUS - FNM were performed. The marked lymph node was isolated during surgery for histological examination. The marked lymph node was isolated for separate histological examination in 56 patients, of whom 22 (39 %) had malignant lymph nodes and 34 (61 %) had benign lymph nodes. There were no complications of EUS - FNM. The sensitivity of EUS for differentiation between malignant and benign lymph nodes was 86 % compared with 55 % - 59 % for the different ESE modalities. The specificity of EUS was 71 % compared with 82 % - 85 % using ESE modalities. The use of the EUS - FNM technique enabled the identification of a specific lymph node and thereby the use of histology as gold standard. ESE and ESE-strain ratio were no better than standard EUS in differentiating between malignant and benign lymph nodes in patients with resectable upper gastrointestinal cancer.
    Endoscopy 07/2012; 44(8):759-66. DOI:10.1055/s-0032-1309817 · 5.20 Impact Factor
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    ABSTRACT: The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature. Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature. This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature. The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.
    Surgical Endoscopy 03/2011; 25(3):804-12. DOI:10.1007/s00464-010-1258-9 · 3.31 Impact Factor
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    ABSTRACT: No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes. Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen. Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications. EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.
    Endoscopy 12/2009; 42(2):133-7. DOI:10.1055/s-0029-1215378 · 5.20 Impact Factor
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    ABSTRACT: Treatment of patients with locally advanced pancreatic cancer remains a challenge, and the exact role of surgery with vascular resection remains unclear. Several studies on selected patient populations have addressed the problem, but with varying results. Although venous resection may be performed without increased morbidity and mortality, the majority of studies found no improved long-term survival when compared to oncological treatment.
    Ugeskrift for laeger 11/2009; 171(46):3360-2.
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    ABSTRACT: Summary The remaining lifetime of patients with inoperable carcinoma of the stomach or pancreas is limited, and an explorative laparotomy performed only to confirm unresectability causes unnecessary emotional and physical stress to the patients. As an alternative we have for the last 18 months performed a laparoscopy in these patients and recorded complications, length of hospital stay and post-operative survival. For comparison we have retrospectively studied the records of similar patients who went through explorative laparotomy during the previous 3 years. Laparoscopy was found to reduce the number of post-operative complications, decrease the length of hospital stay and, when compared with laparotomy, increase the median remaining lifetime by more than 100% (P < 0.01). To reduce the number of futile laparot-omies in patients with incurable carcinoma of the stomach or pancreas, laparoscopy should be performed as an integrated part of the pre-operative assessment procedures.
    Minimally Invasive Therapy & Allied Technologies 07/2009; 3(5):267-270. DOI:10.3109/13645709409153020 · 1.18 Impact Factor
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    ABSTRACT: Noninvasive 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. A 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. Two 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. LUS-guided biopsy is a safe procedure which in combination with laparoscopic biopsies had an impact on patient management in one-quarter of UGIC patients.
    Surgical Endoscopy 05/2009; 23(12):2738-42. DOI:10.1007/s00464-009-0481-8 · 3.31 Impact Factor
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    ABSTRACT: Cancer in the upper gastrointestinal tract has a poor prognosis and the best results are obtained by the few resectable patients. Earlier studies indicated that Danish survival might be inferior to that of other Scandinavian countries. The aim of this study was to evaluate the long-term survival after curative resections for these patients. All patients referred for treatment of cancer of the oesophagus, stomach or pancreas were prospectively included. Data were registered with regard to pre-therapeutic examination and operative results. Deceased patients were found by comparison with the Danish Central Personal Register in January 2007. A total of 398 patients were included, of whom 164 were found to be possibly resectable. In total 118 (30%) patients underwent complete surgical resection. The median survival period for patients with oesophageal cancer, stomach cancer and pancreatic cancer was: 22.7 months (18.7-39.4), above 36 months and 31.4 months (19.2-) respectively. The observed 3-year survival was 40% (26-53), 56% (38-71) and 47% (31-62). The estimated 5-year survival was 35% (22-48), 56% (39-72), 43% (27-59). The observed long-term survival was comparable to international results. However, only one third of the patients were eligible for complete surgical resection. It is therefore important to establish a close cooperation between surgeons and oncologist to improve the overall survival for this group of patients.
    Ugeskrift for laeger 01/2009; 170(49):4040-4.
  • Ugeskrift for laeger 01/2009;
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    ABSTRACT: The enterohepatic circulation of a radioactive marked bile acid (75Se-HCAT) was studied by scintigraphy in the post-prandial period as well as after prolonged fasting in healthy young male volunteers in combination with a continuous pressure recording from the antroduodenal region. In a group of 8 subjects the radioactive marker was instilled into duodenum after the ingestion of a standard meal. At the transition from fed-motility pattern (irregular contractions with a frequency of 1–9 per minute) to fasting intestinal motility pattern, defined as the occurrence of a Phase HI activity-front of the migrating motor complexes, a median (range) of 14% (9–25%) of the 75Se-HCAT pool was stored in the gallbladder. During the following migrating motor complex cycles, net gallbladder filling occurred with a significantly higher rate during Phase I (0.22% of the 75Se-HCAT pool per minute) compared to Phase II, where the median net value was 0.07%. This difference in net filling rate was due to the occurrence of periods of gallbladder emptyings during Phase II. At the end of this first migrating motor complex cycle in the post-prandial period a total of 32% (26–46%) of the 75Se-HCAT pool was in the gallbladder. In another group of 8 subjects the scintigraphic study was not carried out until 15–20 hours after ingestion of the standard meal and the radioactive marker. The scintigraphic study was carried out for two subsequent migrating motor complex cycles, and the amount of the 75Se-HCAT pool present in the gallbladder at the first recorded Phase III complex was 46% (32–52%). The figures at the occurrence of the following two Phase III complexes were 48% (32–65%) and 47% (42–59%), respectively. A cyclic variation in gallbladder filling and emptying in connection with the migrating motor complex cycle was seen with a net filling during Phase I and a net emptying during Phase II. In the study after prolonged fasting the number and duration of the spontaneous gallbladder emptyings in Phase II were not different from those in the post-prandial study. However, the amount emptied in per cent of the 75Se-HCAT pool was significantly higher in the group studied after prolonged fasting compared to the group studied in the postprandial period, and accounted for a median of 3.3% (2.0–16.5%) and (1.6–6.0%) of the 75Se-HCAT pool, respectively. This difference is most likely due to an increase in the concentration of gallbladder bile during fasting.
    Neurogastroenterology and Motility 06/2008; 5(3):153 - 160. DOI:10.1111/j.1365-2982.1993.tb00120.x · 3.42 Impact Factor
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    ABSTRACT: This study was designed to clarify whether a part of the variability in gastric emptying could be ascribed to a relationship between meal ingestion and phase activity of the migrating motor complex and whether reproducibility is increased when meal ingestion takes place in relation to preselected characteristics of the migrating motor complex. We examined 12 healthy males, and the design included three examinations, twice with meal ingestion in a duodenal Phase I, and once in a Phase II. The meal consisted of an omelette labelled with 99mTc followed by 150 ml water labelled with 111In. The results showed that liquid lag phase (min) and was significantly shorter in Phase II than in Phase I (1 vs. 4, P = 0.007). The half emptying time of solid linear phase (min) was reproduced with nearly identical median and range values in the three series (I[1]: 67[51–87]; I[2]: 63[47–80]; 61[47–76]). With meal ingestion in Phase I a significant difference between inter- and intra-individual variance could not be demonstrated. With meal ingestion in Phase I a second examination in Phase I did not increase reproducibility of any of the variables compared to a second examination in Phase II. In conclusion, scientific investigations on gastric emptying have to be performed with phase related meal ingestion and a double-radionuclide technique.
    Neurogastroenterology and Motility 06/2008; 5(4):233 - 238. DOI:10.1111/j.1365-2982.1993.tb00126.x · 3.42 Impact Factor
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    ABSTRACT: Endoscopic ultrasonography (EUS) is an integrated part of the pretherapeutic evaluation program for patients with upper gastrointestinal (GI) tract cancer. Whether the clinical impact of EUS differs between surgeons from different countries is unknown. The same applies to the potential clinical influence of EUS misinterpretations. The aim of this study was to evaluate the interobserver agreement on predefined treatment strategies between surgeons from four different countries, with and without EUS, and to evaluate the clinical consequences of EUS misinterpretations. One hundred patients with upper GI tract cancer were randomly selected from all upper GI tract cancer patients treated at Odense University Hospital between 1997 and 2000. Based on patient records and EUS database results, a case story was created with and without the EUS result for each patient. Four surgeons were asked to select the relevant treatment strategy in each case, at first without knowledge of the EUS and thereafter with the EUS result available. Interobserver agreement and impact of EUS misinterpretations were evaluated using the actual final treatment of each patient as reference. Three of four or all four surgeons agreed on the same treatment strategy for nearly 60% of the patients with and without the EUS results. Treatment decisions were changed in 34% based on the EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%). Interobserver agreement was relatively low, but overall EUS increased kappa values from 0.16 ("poor") to 0.33 ("fair"), thus indicating increased overall agreement after the EUS results were available. EUS conclusion regarding stage or resectability was wrong in 17% of the cases, but only one serious event would have been the clinical result of EUS misinterpretations. Despite being used in different ways by different surgeons, EUS did change patient management in one third of the cases. The impact of EUS misinterpretations seemed very low, and this study confirmed one of the strongest clinical possibilities of EUS, i.e., the ability to detect nonresectable cases. EUS is an important imaging modality for oncosurgeons from different countries.
    Surgical Endoscopy 04/2007; 21(3):431-8. DOI:10.1007/s00464-006-9029-3 · 3.31 Impact Factor
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    ABSTRACT: 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). A total of 411 consecutive patients with UGIC (182 pancreatic cancers, 134 gastric cancers and 95 oesophageal cancers) treated between January 2002 and May 2004 were analysed prospectively. The allocation of patients into resectability groups by endoscopic ultrasonography (EUS) and laparoscopic ultrasonography (LUS) was compared with the treatment actually undertaken. The combination of EUS and LUS correctly predicted R0 resection in 90.6 per cent, R1-R2 in 91 per cent and irresectability in 91.4 per cent of patients. Ten patients (2.4 per cent) had explorative laparotomy only. There were no complications associated with the EUS and LUS procedures. The routine use of EUS and LUS before surgery predicted R0 resection in nine of ten patients and reduced the number of unnecessary laparotomies to less than 3 per cent.
    British Journal of Surgery 06/2006; 93(6):720-5. DOI:10.1002/bjs.5342 · 5.21 Impact Factor
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    ABSTRACT: 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. 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. 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. The combination of EUS and LUS is accurate in identifying the non-resectable patients and has a high predictive value for complete resection.
    HPB 02/2006; 8(1):57-60. DOI:10.1080/13651820500465972 · 2.05 Impact Factor
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    ABSTRACT: Prospective data are lacking on the safety of endoscopic ultrasonography (EUS) and on patient satisfaction with the procedure. We prospectively recorded complications related to EUS in order to establish morbidity and mortality. In addition the levels of patient satisfaction were evaluated, with regard to the tolerability of the procedure (pain, discomfort, and anxiety levels) and the provision of information. 3324 consecutive patients who underwent EUS were studied with regard to complications. During the study period 300 patients were interviewed and followed up in detail as part of the evaluation of patient satisfaction. Ten patients (0.3 %) suffered from a complication related to the EUS procedure, and two patients died (0.06 %). There were no significant differences between the complication rates for EUS-guided fine-needle aspiration (EUS-FNA) and for EUS, but both fatal cases related to EUS-FNA/EUS-guided intervention. Nine of the ten patients with complications (90 %) had a diagnosis of malignancy, and esophageal perforation accounted for half of all complications. Although the majority of patients with nonlethal complications were managed well on conservative regimens, only one case, of self-limiting acute pancreatitis, could be classified as a mild complication. With regard to patient tolerability, only minor incidents occurred during the EUS procedure (tracheal suction 5 %, vomiting 0.3 %, aspiration 0.3 %) and no intervention was necessary. During the procedure, 80 % of the patients had no or only slight pain and more than 95 % experienced only slight or no anxiety, whereas more than half of the patients experienced moderate to severe discomfort. More than 90 % of the patients were satisfied or very satisfied with the information provided to them before and after the EUS, and the same number of patients were ready without hesitation to undergo an additional EUS examination if necessary. EUS, EUS-FNA and EUS-guided intervention are safe techniques, but severe and lethal complications do occur. The EUS procedures can be performed with a high level of patient satisfaction and with low levels of pain, discomfort and anxiety.
    Endoscopy 03/2005; 37(2):146-53. DOI:10.1055/s-2005-861142 · 5.20 Impact Factor
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    C W Fristrup · T Pless · J Durup · M B Mortensen · H O Nielsen · C P Hovendal
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    ABSTRACT: Laparoscopic 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. Three-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. Both 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. The use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking.
    Surgical Endoscopy 12/2004; 18(11):1601-4. DOI:10.1007/s00464-003-9282-7 · 3.31 Impact Factor
  • N Buch · H Glad · P Svendsen · H R Witek Oxlund · F Gottrup · C P Hovendal
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    ABSTRACT: To compare healing of one-layer colonic anastomoses with or without a soluble intraluminal prosthesis (* SBS-tube). Randomised, partly blinded controlled study. University hospital, Denmark. 16 female Danish country strain pigs, of which 8 had the SBS tube inserted and 8 acted as controls. One-layer colonic anastomoses either hand-sewn (n = 8, controls) or hand-sewn onto an SBS tube (n = 8). Macroscopic evaluation, leakage test, breaking strength, histology, oxygen tension in and near the anastomosis peroperatively and 4 days postoperatively. Three quarters of the tubes (n = 8) dissolved in less than 2 hours. Histological examination showed significantly better structured layers and more mucosal epithelial covering in the SBS group. The other histological variables examined were: tissue gap (p < 0.08), inflammation (p < 0.10), breaking strength (p < 0.46) and amount of granulation tissue (p < 0.71), but the last findings were not significant. Oxygen tension at the anastomotic line was better in the SBS tube group, but not significantly so. We conclude that the SBS tube facilitates the sewing of the anastomosis and may improve healing, possibly because of better apposition of the cut ends and reduced tension in the sutures.
    The European Journal of Surgery 05/2002; 168(3):165-71. DOI:10.1080/110241502320127784
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    ABSTRACT: Laparoscopic ultrasonography (LUS) is an important imaging modality during laparoscopic staging of intra-abdominal malignancies, but LUS-assisted biopsy is often difficult or impossible. We report a newly developed inbuilt biopsy system for direct LUS-guided fine-needle aspiration (FNA) and Tru-cut biopsies. LUS-guided biopsy was performed in 20 patients with upper gastrointestinal tract tumors. The biopsied lesions had either not been previously detected by other imaging modalities or had been inaccessible, or the biopsy sample had been inadequate. Primary diagnosis, duration of biopsy procedure, needle monitoring (visibility, penetration, and deviation), complications, technical failures, and pathological findings were prospectively recorded. 44 biopsies were performed with 25 needles (19, 20, and 22-G). Needle monitoring and penetration were good or acceptable in 18 patients (90%). Slight needle deviation (<10 mm) was seen in eight patients (40%). The LUS-guided biopsy specimen was sufficient for analysis in 13 patients (65%). In two additional patients, adequate material was obtained, but pathological examination was impossible owing to incorrect handling of the specimen. The biopsy procedures lasted 16.3 minutes (range 10-20 minutes) and no complications were seen. LUS-guided fine-needle aspiration or Trucut biopsy is possible using this newly developed biopsy system. These preliminary data suggest that LUS-guided biopsy may further improve the diagnostic possibilities of LUS.
    Endoscopy 08/2001; 33(7):585-9. DOI:10.1055/s-2001-15319 · 5.20 Impact Factor
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    ABSTRACT: Several studies have evaluated the accuracy of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) in the upper gastrointestinal tract, but so far no studies have specifically evaluated the clinical impact of EUS-FNAB in upper gastrointestinal tract cancer patients. In this consecutive and prospective study, EUS-FNAB was only performed if a positive malignant finding would change the therapeutic strategy. Between 1997 and 1999, 307 consecutive patients were referred for EUS with a diagnosis or strong suspicion of esophageal, gastric or pancreatic cancer; 274 patients were potential candidates for surgical treatment and had EUS. According to predefined impact criteria, 27% (75/274) of the patients had EUS-FNAB for staging or diagnostic reasons. The overall clinical impact of EUS-FNAB was 13%, 14%, and 30% in esophageal, gastric, and pancreatic cancer, respectively. The staging-related clinical impact was similar for all three types of cancer (11-12.5%), whereas the diagnosis-related impact was highest in pancreatic cancer patients (86%). EUS-FNAB was inadequate in 13% and gave false-negative results in 5%. The overall sensitivity, specificity and accuracy for EUS-FNAB were 80%, 78% and 80%, respectively. No complications related to the biopsy procedure were seen. If EUS-FNAB was performed only in cases where a positive malignant result would change patient management, then approximately one out of four patients with upper gastrointestinal tract cancer would require a biopsy. With this approach the actual clinical impact of EUS-FNAB ranged from 13% in esophageal cancer to 30% in pancreatic cancer. EUS-FNAB plays a limited, but very important clinical role in the assessment of upper gastrointestinal tract cancer.
    Endoscopy 07/2001; 33(6):478-83. DOI:10.1055/s-2001-14966 · 5.20 Impact Factor
  • P B Mortensen · J F Larsen · T Nilsson · H O Nielsen · C P Hovendal
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    ABSTRACT: Extended lymphadenectomy on connection with the surgical treatment of gastric cancer is gaining access in western centres especially since Japanese centres have shown an ever increasing rate of survival over several decades, coupled with the fact that operative procedures have become more sophisticated. The latest prospective studies in the west seem to confirm the value of lymphadenectomy in some patients. Furthermore, correct staging demands extended lymphadenectomy. For patients with gastric cancer, adjuvant preoperative chemotherapy is probably an asset.
    Ugeskrift for laeger 03/2001; 163(9):1247-50.