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A M Joyce, N A Ahmad,
M C Beilstein,
M L Kochman,
W B Long,
T Baron,
S Sherman,
E Fogel,
G A Lehman,
L McHenry,
J Watkins,
G G Ginsberg
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ABSTRACT: A new duodenoscope (the V-scope), with a modified elevator used in combination with a dedicated short guide wire, constitutes the V-system. This system is intended to allow fixation of the guide wire at the elevator lever, thereby enhancing the speed and reliability of accessory exchange over a guide wire during ERCP. The aim of this study was to evaluate the extent to which the V-system provides improved efficiency in comparison with conventional duodenoscope and guide wire combinations.
This was an industry-sponsored multicenter randomized trial. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) procedures in which treatment was anticipated were randomly assigned to the V-system or to a conventional duodenoscope and accessories used routinely in each center. The parameters recorded included the total case time, fluoroscopy time, catheter/guide wire exchange time, guide wire repositioning, loss of guide wire access, and success or failure of guide wire fixation when using the V-system.
Fifty patients were included, 22 in the conventional group and 28 in the V-system group. A total of 135 exchanges were carried out. The patients had up to six exchanges. The median exchange time was 19.4 s with the V-system and 31.7 s with the conventional systems ( P < 0.001). Guide wire repositioning was required less often in the V-system group ( P = 0.0005). The V-system effectively locked the guide wire in 63 of 71 exchanges (89 %). Loss of guide wire access occurred in two patients in the conventional group and four in the V-system group, attributable to failure to lock the guide wire early during the experience (no significant differences).
The V-system can effectively secure the guide wire during accessory exchange in ERCP and reduces the time required to exchange accessories. This may enhance overall efficiency during ERCP.
Endoscopy 08/2006; 38(7):713-6. · 5.21 Impact Factor
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Journal of the Pakistan Medical Association 01/2003; 52(12):576-8.
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ABSTRACT: The aim of this study was to evaluate the ability of endoscopic ultrasound (EUS) alone to predict and differentiate malignant from benign cystic lesions of the pancreas.
From January, 1995, to August, 1999, 98 cases of pancreatic cystic lesions were evaluated by EUS; all of these were originally imaged by cross-sectional modalities that were not diagnostic. Among these, surgical/pathological correlation was available in 48 patients. The original endosonographic images were reviewed by two endosonographers who were blinded to each other's interpretation and to the surgical and pathological interpretation. The EUS images were assessed for the presence or absence of the following characteristics: 1) wall, 2) solid component, 3) septae, 4) lymphadenopathy, and 5) number of cysts. These characteristics were then correlated with the surgical and pathological findings and were assessed to determine if any were predictors of the lesion being benign or malignant.
For reviewer A, the presence of a solid component by EUS was the only statistically significant predictor of malignancy (odds ratio = 4.73, 95% CI = 1.13-19.68, p = 0.03). However, 61% of patients with benign lesions were also interpreted by EUS to have a solid component. For reviewer B, none of the features were found to be significant predictors of a malignant lesion. When the results of both reviewers were combined, the presence of a solid component was not found to be a statistically significant predictor of malignancy (odds ratio = 1.046, 95% CI = 0.99-1.09, p = 0.07).
Endosonographic features cannot reliably differentiate between benign and malignant cystic lesions of the pancreas after a nondiagnostic cross-sectional modality.
The American Journal of Gastroenterology 01/2002; 96(12):3295-300. · 7.28 Impact Factor
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ABSTRACT: The aim of this study was to determine the long term survival of patients with pancreatic adenocarcinoma who underwent surgical resection and to assess the association of clinical, pathological, and treatment features with survival.
Between January, 1990, and December, 1998, 125 patients underwent a pancreaticoduodenal or partial pancreatic resection for pancreatic ductal adenocarcinoma at our institution. The records of these patients were reviewed for demographics, tumor characteristics including size, histological grade, margin status, lymph node status, surgical TNM staging, and postoperative adjuvant therapy. The primary outcome variable analyzed was survival.
A total of 116 patients had complete follow-up and were included in the final analysis. The median survival after surgery was 16 months. The 1-, 3-, 5-, and 7-yr survival rates for all 116 patients were 60%, 23%, 19%, and 11%, respectively. The 1-, 3-, 5-, and 7-yr survival rates for patients who received adjuvant therapy were 69%, 28%, 23%, and 18% compared with 20% and 0% in patients who did not receive adjuvant therapy (p < 0.0001). The 1-, 3-, 5-, and 7-yr survival rates for patients with negative lymph nodes were 73%, 38%, 26%, and 22% compared with survival rates of 52%, 14%, 14%, and 9% in patients with positive lymph nodes (p = 0.01). In multivariate analyses, adjuvant therapy was the only feature found to be strongly associated with survival (hazards ratio = 0.26, 95% CI = 0.15-0.44).
The overall 5- and 7-yr survival rates of 19% and 11% in our study further validate that surgical resection in patients with pancreatic adenocarcinoma can result in long term survival, particularly when performed in association with adjuvant chemoradiation.
The American Journal of Gastroenterology 09/2001; 96(9):2609-15. · 7.28 Impact Factor
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ABSTRACT: Surgical exploration in patients with pancreatic carcinoma without adequate preoperative attempts to determine resectability results in resection in only a minority of patients. Besides distant metastases, involvement of the major vessels is the most important parameter for determining resectability in patients with pancreatic adenocarcinoma. Angiography has been an integral part of pancreatic cancer staging. Lately, endoscopic ultrasound (EUS) has emerged as a more accurate tool in the diagnosis and staging of pancreatic cancer. We hypothesize that EUS is more accurate than selective venous angiography (SVA) for assessing resectability of pancreatic adenocarcinoma based on preoperative evaluation of vascular involvement. Twenty-one patients who met the inclusion criteria were prospectively evaluated with both EUS and SVA before undergoing surgical exploration for attempted curative resection. Vascular involvement was determined by EUS and SVA using previously described criteria. The sensitivity, specificity, and overall accuracy of EUS and SVA in assessing vascular involvement were compared, using surgical exploration as the gold standard. Endoscopic ultrasound had a higher sensitivity than SVA for detecting vascular involvement (86% vs. 21%, respectively; p = 0.0018). The specificity and accuracy of EUS for detecting vascular involvement was 71% and 81%, respectively. In contrast, the specificity and accuracy of SVA for detecting vascular involvement was 71% and 38%, respectively. Endoscopic ultrasound is significantly more sensitive than angiography for detecting vascu lar involvement in patients with pancreatic adenocarcinoma and, thus, may improve patient selection for attempted curative resection.
Journal of Clinical Gastroenterology 02/2001; 32(1):54-8. · 3.16 Impact Factor
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Seminars in Roentgenology 11/2000; 35(4):404-8. · 0.66 Impact Factor
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ABSTRACT: Endoscopic ultrasound (EUS) is believed to be highly accurate in the local (T) and nodal (N) staging of pancreatic cancer. However, there are scant data concerning the predictive value of EUS for resectability of pancreatic adenocarcinoma. This study was performed to determine the accuracy of TNM staging by EUS in patients with pancreatic adenocarcinoma and to evaluate the role of preoperative TNM staging by EUS for determining resectability in patients with pancreatic adenocarcinoma.
This is a retrospective review of a cohort of 89 patients evaluated preoperatively with EUS for pancreatic adenocarcinoma between January 1995 and December 1997. Preoperative TNM classification by EUS was compared with surgical and histopathologic TNM staging. Resectability rates were determined and compared with the preoperative TNM staging by EUS.
The overall accuracy of EUS for T and N staging was found to be 69% and 54%, respectively. The overall proportion of tumors that were deemed resectable by EUS and were actually found to be resectable during surgical exploration was 46%. The proportion of tumors staged as T4 N1, T4 N0, T3 N1 and T3 N0 by EUS that were found to be resectable during surgical exploration was 45%, 37%, 44% and 62%, respectively.
In a tertiary referral patient population, EUS is not as accurate as previously reported in the T and N staging of pancreatic cancer. EUS is also not predictive of resectability in stage T3 or T4 pancreatic cancer.
Gastrointestinal Endoscopy 11/2000; 52(4):463-8. · 4.88 Impact Factor
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ABSTRACT: Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) have both been assessed individually as staging modalities for pancreatic cancer. The aim of our study was to assess whether tumor staging by both EUS and MRI in the same cohort of patients could predict resectability and unresectability in patients with pancreatic cancer.
A review of 63 patients evaluated preoperatively with both EUS and MRI for pancreatic adenocarcinoma between January 1995 and December 1998 was done. Patients were staged as resectable or unresectable by predefined criteria. Preoperative staging by both modalities was compared to surgical outcome and the sensitivity and predictive values of each modality for determining resectability and unresectability was determined.
EUS did not allow for complete T- and N-staging in 10 patients; therefore, for EUS, the final analysis was done on 63 of 73 patients (86%). EUS correctly staged 22 of 36 patients with resectable tumors. The sensitivity of EUS for resectability was 61%, with a positive predictive value of 69%. All 73 patients had complete MRI examinations; therefore, the final analysis was done on all 73 patients. MRI correctly staged 30 of 41 patients with resectable tumors. The sensitivity of MRI for predicting resectability was 73% with a positive predictive value of 77%. MRI and EUS both predicted resectability in 18 patients, of whom 16 (89%) were found to be resectable on surgical exploration. MRI and EUS both predicted unresectability in 17 (27%) patients, of whom 4 (24%) were found to be resectable on surgical exploration. When both MRI and EUS agreed on resectability, the positive predictive value for resectability was 89%. When both MRI and EUS agreed on unresectability, the positive predictive value for unresectability was 76%.
Neither MRI nor EUS alone were highly sensitive or predictive of resectability. However, when both tests agreed on resectability, nearly all patients were found to be resectable on surgical exploration.
The American Journal of Gastroenterology 09/2000; 95(8):1926-31. · 7.28 Impact Factor
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ABSTRACT: Dyspepsia and heartburn are the two cardinal symptoms of foregut dysfunction. When confronting such a problem, that physician must first learn to discern between the two, because treatment can be quite different for the conditions presenting with these symptoms. This article details the approach to work-up and treatment of patients presenting with dyspepsia or heartburn.
Rheumatic Disease Clinics of North America 09/1999; 25(3):703-18, x. · 3.02 Impact Factor
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ABSTRACT: To describe two patients with concurrent Zollinger-Ellison syndrome and ectopic production of corticotropin in whom Cushing's syndrome was managed surgically.
Two case vignettes are presented, and a general approach is discussed for determining a management strategy for optimal potential for survival.
The prognosis associated with medical management of patients with sporadic Zollinger-Ellison syndrome and Cushing's syndrome attributable to ectopic production of adrenocorticotropic hormone (corticotropin) is dismal. Two surgical options may yield improved outcomes. The first approach is bilateral adrenalectomy followed by replacement therapy with corticosteroids and mineralocorticoids. The second surgical approach consists of removal of the organ producing the corticotropin (the liver) and performance of hepatic transplantation. These two treatment strategies were used in our two patients, both of whom had widely metastatic disease at the time of initial assessment. The patient who underwent bilateral adrenalectomy continued to do well 4 years postoperatively.
Treatment of patients with Zollinger-Ellison syndrome and ectopic production of corticotropin presents a challenge. Because results with medical therapy have been suboptimal, aggressive surgical intervention seems warranted.
Endocrine Practice 5(5):261-5. · 2.49 Impact Factor
