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Stornello C, Cristofori C, Checchin D, de Palo MG, Grillo S, Peserico G, Quintini D, Gruppo M, De Simoni O, Fantin A. The Role of Endoscopic Ultrasound in Ampullary Lesion Management. Diagnostics (Basel) 2024; 14:1855. [PMID: 39272640 PMCID: PMC11394035 DOI: 10.3390/diagnostics14171855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/07/2024] [Accepted: 08/21/2024] [Indexed: 09/15/2024] Open
Abstract
Ampullary lesions, neoplasms originating in the papilla of Vater, represent a rare yet clinically significant group of tumors with diverse etiologies and management challenges. This comprehensive review aims to elucidate the pivotal role of endoscopic ultrasound (EUS) in the diagnosis, staging, and management of ampullary lesions. This review begins by providing an overview of ampullary lesions, their epidemiology, and associated risk factors. We delve into their clinical presentation, emphasizing the importance of early and accurate diagnosis. Furthermore, we explore the limitations of traditional diagnostic modalities and highlight the growing relevance of EUS in ampullary lesion evaluation. We discuss the superior spatial resolution of EUS in comparison with other imaging methods, and we present an in-depth analysis of EUS-guided sampling and its pivotal role in obtaining histological samples for accurate diagnosis. In addition to diagnosis, we examine the indispensable role of EUS in ampullary lesion staging and its clinical implications. Furthermore, we discuss the potential of EUS in the surveillance and follow-up of ampullary lesions, ensuring timely detection of recurrence and monitoring treatment response in sporadic cases and in the context of familial syndromes, such as familial adenomatous polyposis (FAP). In conclusion, this review underscores the indispensable role of endoscopic ultrasound in the multifaceted approach to ampullary lesion evaluation. EUS not only enhances diagnostic accuracy but also informs treatment decisions and minimally invasive therapeutic interventions. As our understanding of ampullary lesions continues to evolve, EUS remains an invaluable tool for the improvement of patient outcomes and quality of life.
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Affiliation(s)
- Caterina Stornello
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Chiara Cristofori
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Davide Checchin
- Gastroenterology Unit, Dell'Angelo Hospital, 30174 Venice, Italy
| | - Maria Grazia de Palo
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Sabina Grillo
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Giulia Peserico
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Dario Quintini
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Mario Gruppo
- Unit of Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Ottavia De Simoni
- Unit of Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
| | - Alberto Fantin
- Gastroenterology Unit, Veneto Institute of Oncology IOV-IRCCS, 35100 Padua, Italy
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Xin X, Jian J, Fan X, Qi B, Zhao Y, Lv W, Zhao Y, Zhao X, Hu C. Multiscale X-ray phase-contrast CT unveils the evolution of bile infarct in obstructive biliary disease. Commun Biol 2024; 7:490. [PMID: 38654111 PMCID: PMC11039475 DOI: 10.1038/s42003-024-06185-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
Bile infarct is a pivotal characteristic of obstructive biliary disease, but its evolution during the disease progression remains unclear. Our objective, therefore, is to explore morphological alterations of the bile infarct in the disease course by means of multiscale X-ray phase-contrast CT. Bile duct ligation is performed in mice to mimic the obstructive biliary disease. Intact liver lobes of the mice are scanned by phase-contrast CT at various resolution scales. Phase-contrast CT clearly presents three-dimensional (3D) images of the bile infarcts down to the submicron level with good correlation with histological images. The CT data illustrates that the infarct first appears on day 1 post-BDL, while a microchannel between the infarct and hepatic sinusoids is identified, the number of which increases with the disease progression. A 3D model of hepatic acinus is proposed, in which the infarct starts around the portal veins (zone I) and gradually progresses towards the central veins (zone III) during the disease process. Multiscale phase-contrast CT offers the comprehensive analysis of the evolutionary features of the bile infarct in obstructive biliary disease. During the course of the disease, the bile infarcts develop infarct-sinusoidal microchannels and gradually occupy the whole liver, promoting the disease progression.
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Affiliation(s)
- Xiaohong Xin
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China
| | - Jianbo Jian
- Department of Radiation Oncology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Xu Fan
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis and National Clinical Research Center of Digestive Disease, Beijing, 100050, China
| | - Beining Qi
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China
| | - Yuanyuan Zhao
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China
| | - Wenjuan Lv
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China
| | - Yuqing Zhao
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China
| | - Xinyan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
- Beijing Key Laboratory of Translational Medicine on Liver Cirrhosis and National Clinical Research Center of Digestive Disease, Beijing, 100050, China.
| | - Chunhong Hu
- School of Biomedical Engineering and Technology, Tianjin Medical University, Tianjin, 300070, China.
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Eissa M, Okasha HH, Abbasy M, Khamis AK, Abdellatef A, Rady MA. Role of endoscopic ultrasound in evaluation of patients with missed common bile duct stones. World J Gastrointest Endosc 2022; 14:564-574. [PMID: 36186945 PMCID: PMC9516471 DOI: 10.4253/wjge.v14.i9.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/26/2022] [Accepted: 09/06/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Choledocholithiasis develops in up to 20% of patients with gall bladder stones. The challenge in diagnosis usually occurs with small stones that may be missed by magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound (EUS) is accurate in detecting common bile duct (CBD) stones missed by MRCP, especially the small ones or those impacted at the distal CBD or the papillary region.
AIM To evaluate the accuracy of EUS in detecting CBD stones missed by MRCP.
METHODS Patients with an intermediate likelihood of choledocholithiasis according to ESGE guidelines and those with acute pancreatitis of undetermined cause were included. The presence of choledocholithiasis was evaluated by MRCP and EUS, and then results were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The sensitivity and specificity of EUS and MRCP were compared regarding the presence of stones, the size, and the number of detected stones.
RESULTS Ninety out of 100 involved patients had choledocholithiasis, while ten patients were excluded as they had pancreatic or gall bladder masses during EUS examination. In choledocholithiasis patients, the mean age was 52.37 ± 14.64 years, and 52.2% were males. Most patients had biliary obstruction (74.4%), while only 23 (25.6%) patients had unexplained pancreatitis. The overall prevalence of choledocholithiasis was 83.3% by EUS, 41.1% by MRCP, and 74.4% by ERCP. Also, the number and size of CBD stones could be detected accurately in 78.2% and 75.6% by EUS and 41.1% and 70.3% by MRCP, respectively. The sensitivity of EUS was higher than that of MRCP (98.51% vs 55.22%), and their predictive value was statistically different (P < 0.001). Combination of both tools raised the sensitivity to 97.22% and specificity to 100%.
CONCLUSION EUS could be a useful tool in assessing patients with suspected choledocholithiasis especially if combined with MRCP. However, its usefulness depends on its availability and the experience of the local centers.
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Affiliation(s)
- Mohamed Eissa
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Menoufia 32951, Egypt
| | - Hussein Hassan Okasha
- Department of Internal Medicine, Hepatogastroenterology Division, Kasr AL-Ainy School of Medicine, Cairo University, Cairo 11451, Egypt
| | - Mohamed Abbasy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Menoufia 32951, Egypt
| | - Ahmed Kamal Khamis
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Menoufia 32951, Egypt
| | - Abeer Abdellatef
- Department of Internal Medicine, Hepatogastroenterology Division, Kasr AL-Ainy School of Medicine, Cairo University, Cairo 11451, Egypt
| | - Mohamed Akl Rady
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Menoufia 32951, Egypt
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May SA, Korotkevich AG, Leontiev AS, Shestak IS, Savostyanov IV. Tactics and techniques of choledochal sanation after papillotomy. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2021; 1:49-56. [DOI: 10.31146/1682-8658-ecg-189-5-49-56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Сholelithiasis ranks third in terms of the prevalence of diseases among the adult population. A complication such as choledocholithiasis occurs in up to 33% of patients with gallstone disease. Despite the improvement in treatment methods and the use of “gold” standards, the number of complicated forms of cholelithiasis has no tendency to decrease. Timely resolution of choledocholithiasis by a correctly chosen technique helps to reduce complications and increases the frequency of favorable outcomes of the disease, returning patients to social activity.That is why it is important to know and, if possible, to use various methods of rehabilitation of the common bile duct when performing modern endoscopic transpapillary interventions.
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Affiliation(s)
- S. A. May
- “Novokuznetskaya City Clinical Hospital № 29”
| | - A. G. Korotkevich
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
| | - A. S. Leontiev
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
| | | | - I. V. Savostyanov
- “Novokuznetskaya City Clinical Hospital № 29”; Novokuznetsk State Institute of Advanced Medical
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Fang A, Kim IK, Ukeh I, Etezadi V, Kim HS. Percutaneous Management of Benign Biliary Strictures. Semin Intervent Radiol 2021; 38:291-299. [PMID: 34393339 DOI: 10.1055/s-0041-1731087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.
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Affiliation(s)
- Adam Fang
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Il Kyoon Kim
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ifechi Ukeh
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vahid Etezadi
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hyun S Kim
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Benign Bile Duct Strictures. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Okuno M, Mukai T, Iwata S, Tezuka R, Mita N, Uemura S, Iwashita T, Maruta A, Iwata K, Tomita E, Shimizu M. Preoperative perihilar cholangiocarcinoma assessment using virtual endoscopic imaging magnetic resonance cholangioscopy. Endosc Int Open 2021; 9:E1158-E1163. [PMID: 34222642 PMCID: PMC8218596 DOI: 10.1055/a-1401-9962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/15/2021] [Indexed: 11/09/2022] Open
Abstract
Background and study aims Preoperative assessment of the superficial ductal spread (SDS) of perihilar cholangiocarcinoma (PCCA) is important for determining its resectability. A virtual endoscopic imaging method, magnetic resonance cholangioscopy (MRCS), wherein a three-dimensional image is created from magnetic resonance imaging (MRI) data, can evaluate all aspects of arbitrary bile ducts. Patients and methods Overall, 15 patients with PCCA who underwent preoperative MRI were enrolled. All patients underwent surgical treatment. Results MRCS could be performed based on preoperative MRI data in all patients. MRCS could not be used in one patient due to debris in the obstructed bile duct. The remaining 14 patients (93 %) were diagnosed with obstructed bile duct or irregular surface of the bile duct, signifying tumor invasion. The accuracy rate of diagnosing the SDS was 93 % (14/15). Seven patients underwent preoperative peroral cholangioscopy; the scope could not pass through the tumor in three patients. In these three patients, MRCS was able to be use dtoevaluate the obstructed side of the bile duct and faciliated accurate diagnosis of SDS. Conclusions MRCS can be used to noninvasively evaluate the bile duct in all directions. This novel method makes it easy to create virtual images and can be useful for diagnosing the preoperative SDS of PCCA.
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Affiliation(s)
- Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shota Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Ryuichi Tezuka
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Naoya Mita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefecture General Medical Center, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefecture General Medical Center, Gifu, Japan
| | - Eiichi Tomita
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Maruta A, Iwashita T, Uemura S, Yoshida K, Yasuda I, Shimizu M. Efficacy of the Endoscopic Ultrasound-first Approach in Patients with Suspected Common Bile Duct Stone to Avoid Unnecessary Endoscopic Retrograde Cholangiopancreatography. Intern Med 2019; 58:1673-1679. [PMID: 30799342 PMCID: PMC6630128 DOI: 10.2169/internalmedicine.2047-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective Endoscopic ultrasound (EUS) is a safe and accurate examination for evaluating the presence of common bile duct stones (CBDSs). The EUS-first approach, where EUS is performed before endoscopic retrograde cholangiopancreatography (ERCP) for patients suspected of having CBDSs, may help reduce the risk of ERCP-related adverse events and save manpower by avoiding unnecessary ERCP. To evaluate the efficacy of the EUS-first approach in patients with suspected CBDSs. Methods Between April 2012 and March 2016, 104 patients who underwent the EUS-first approach for suspected CBDSs were retrospectively evaluated. The relevant outcomes were the short- and long-term adverse event rates and the ERCP avoidance rate. Results EUS findings were positive for CBDSs in 52 patients, showed sludge formation or possible CBDSs in 4 patients, and were negative for CBDSs in 42 patients (but positive for other diseases in 6). Sixty-two patients (62/104, 59.6%) underwent ERCP, and proper treatments were successfully performed in all but 1 who underwent only cholangiography. In the remaining 42 patients (42/104, 40.4%), ERCP was omitted based on the EUS findings. Early adverse events were recognized in 0% of the EUS-only group and 8 patients (12.9%) in the EUS+ERCP group (p=0.02). Regarding late adverse events, recurrent CBDSs occurred in 1 patient (2.3%) in the EUS-only group and 2 (3.2%) in the EUS+ERCP group (p=1.0). Conclusion The EUS-first approach in patients with suspected CBDSs was useful for reducing early adverse events associated with ERCP without increasing the late adverse event rate, as EUS enabled the avoidance of unnecessary ERCP.
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Affiliation(s)
- Akinori Maruta
- First Department of Internal Medicine, Gifu University Hospital, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Japan
| | - Kensaku Yoshida
- First Department of Internal Medicine, Gifu University Hospital, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Japan
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Sejpal DV, Trindade AJ, Lee C, Miller LS, Benias PC, Inamdar S, Singh G, Stewart M, George BJ, Vegesna AK. Digital cholangioscopy can detect residual biliary stones missed by occlusion cholangiogram in ERCP: a prospective tandem study. Endosc Int Open 2019; 7:E608-E614. [PMID: 30993165 PMCID: PMC6461551 DOI: 10.1055/a-0842-6450] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims After stone removal in endoscopic retrograde cholangiopancreatography (ERCP), an occlusion cholangiogram (OC) is performed to confirm bile duct clearance. OC can miss residual stones that can lead to recurrent biliary symptoms. The aim of this study was to assess if digital peroral cholangioscopy (POC) increased the diagnostic yield of residual biliary stones that are missed with OC. Patients and methods Patients having ERCP performed for choledocholithiasis were enrolled into the study only if they had one of the following criteria: dilated bile duct ≥ 12 mm and/or if lithotripsy was being performed. An OC was performed to confirm duct clearance after removal of stones followed by POC, based on inclusion criteria. The incremental yield of biliary stones missed by OC but confirmed by POC was then measured. A total of 96 POC procedures were performed on 93 patients in two tertiary care centers. Results Residual biliary stones were found in 34 % of cases. The average bile duct size in cases with residual stones was 15.1 mm ± 0.7 mm. One- to three-mm stones were found in 41 % of cases, 4- to 7-mm stones in 45 % of cases, and ≥ 8-mm stones in 14 % of cases. Lithotripsy was performed in 13 % of cases and was significantly associated with residual stones (30 % vs. 3 %, P < 0.001). Conclusions Occlusion cholangiogram can miss residual stones in patients with dilated bile ducts and those receiving lithotripsy. Digital POC can increase the yield of residual stone detection in these patients and should be considered to confirm clearance of stones. (ClinicalTrials.gov-NCT03482375).
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Affiliation(s)
- Divyesh V. Sejpal
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States,Corresponding author Divyesh Sejpal, MD, MHCDS, FASGE, FACG, AGAF Professor of MedicineChief of EndoscopyNorthwell HealthZucker School of Medicine at Hofstra/Northwell+1-516-562-2683
| | - Arvind J. Trindade
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States,Long Island Jewish Medical Center, New Hyde Park, New York, United States
| | - Calvin Lee
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Larry S. Miller
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States,Long Island Jewish Medical Center, New Hyde Park, New York, United States
| | - Petros C. Benias
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Sumant Inamdar
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Gurshawn Singh
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Molly Stewart
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Benley J. George
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States,Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Anil K. Vegesna
- Long Island Jewish Medical Center, New Hyde Park, New York, United States,The Feinstein Institute for Medical Research
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Meeralam Y, Al-Shammari K, Yaghoobi M. Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis: a meta-analysis of diagnostic test accuracy in head-to-head studies. Gastrointest Endosc 2017. [PMID: 28645544 DOI: 10.1016/j.gie.2017.06.009] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS There is a wide range of reported sensitivity and specificity for EUS and MRCP in the diagnosis of choledocholithiasis, with lack of a proper meta-analysis of diagnostic test accuracy by using head-to-head comparison. Here, we aimed to compare the diagnostic accuracy of EUS and MRCP in detecting choledocholithiasis by using appropriate methodology recommended by the Cochrane Collaboration. METHODS A comprehensive electronic literature search up to January 2017 was done by 2 reviewers for prospective cohort studies comparing EUS and MRCP to a reference standard for detecting choledocholithiasis. The acceptable reference standards were considered ERCP, intraoperative cholangiography, or clinical follow-up >3 months for negative cases. Quality of the included studies was measured by using the QUADAS-2 tool. A bivariate hierarchical model was used to perform the meta-analysis of diagnostic test accuracy. Summary receiver operating characteristics were developed and the area under the curve was calculated. RESULTS A total of 5 of 32 studies were included. No study presented a high risk of bias. The pooled sensitivity and specificity were 0.97 (range, 0.91-0.99) and 0.90 (range, 0.83-0.94) for EUS and 0.87 (range, 0.80-0.93) and 0.92 (range, 0.87-0.96) for MRCP. The overall diagnostic odds ratio of EUS was significantly higher than the one with MRCP (162.5 vs 79.0, respectively; P = .008). Further analysis showed that this was mainly due to the significantly higher sensitivity of EUS as compared with that of MRCP (P = .006). The specificity was not significantly different between 2 modalities (P = .42). CONCLUSION Both EUS and MRCP provide good diagnostic accuracy, with EUS providing statically better diagnostic accuracy and sensitivity, with comparable specificity. EUS should be incorporated in the diagnostic algorithm in patients suspected of choledocholithiasis whenever appropriate.
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Affiliation(s)
- Yaser Meeralam
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Khalil Al-Shammari
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
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Jeon TJ, Cho JH, Kim YS, Song SY, Park JY. Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan. Gut Liver 2017; 11:290-297. [PMID: 27965473 PMCID: PMC5347655 DOI: 10.5009/gnl16052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/19/2016] [Accepted: 06/30/2016] [Indexed: 01/07/2023] Open
Abstract
Background/Aims When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings. Methods Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group. Results EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis. Conclusions An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.
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Affiliation(s)
- Tae Joo Jeon
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.,Department of Internal Medicine, The Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeon Suk Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Si Young Song
- Department of Internal Medicine, The Graduate School, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Young Park
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Abstract
Differentiating benign and malignant biliary strictures is a challenging and important clinical scenario. The typical presentation is indolent and involves elevation of liver enzymes, constitutional symptoms, and obstructive jaundice with or without superimposed or recurrent cholangitis. While overall the most common causes of biliary strictures are malignant, including cholangiocarcinoma and pancreatic adenocarcinoma, benign strictures encompass a wide spectrum of etiologies including iatrogenic, autoimmune, infectious, inflammatory, and congenital. Imaging plays a crucial role in evaluating strictures, characterizing their extent, and providing clues to the ultimate source of biliary obstruction. While ultrasound is a good screening tool for biliary ductal dilatation, it is limited by a poor negative predictive value. Magnetic resonance cholangiopancreatography is more than 95% sensitive and specific for detecting biliary strictures with the benefit of precise anatomic localization. Other commonly employed imaging modalities include endoscopic retrograde cholangiopancreatography with endoscopic ultrasound, contrast-enhanced CT, and cholangiography. First-line treatment of benign biliary strictures is endoscopic dilation and stenting. In patients with anatomy that precludes endoscopic cannulation, percutaneous biliary drain insertion and balloon dilation is preferred.
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Affiliation(s)
- Ashley Altman
- Department of Radiology, The University of Chicago, Chicago, Illinois
| | - Steven M Zangan
- Department of Radiology, The University of Chicago, Chicago, Illinois
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13
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EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65:146-181. [PMID: 27085810 DOI: 10.1016/j.jhep.2016.03.005] [Citation(s) in RCA: 329] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
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De Castro VL, Moura EG, Chaves DM, Bernardo WM, Matuguma SE, Artifon EL. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography in suspected choledocholithiasis: A systematic review. Endosc Ultrasound 2016; 5:118-28. [PMID: 27080611 PMCID: PMC4850791 DOI: 10.4103/2303-9027.180476] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 12/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is a lack of consensus about the optimal noninvasive strategy for patients with suspected choledocholithiasis. Two previous systematic reviews used different methodologies not based on pretest probabilities that demonstrated no statistically significant difference between Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) for the detection of choledocholithiasis. In this article, we made a comparison of the diagnostic ability of EUS and MRCP to detect choledocholithiasis in suspected patients. METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations with all published randomized prospective trials. We performed the systemic review using MedLine, EMBASE, Cochrane, LILACS, and Scopus reviews through May 2015. We identified eight randomized, prospective, blinded trials comparing EUS and MRCP. All the patients were submitted to a gold standard method. We calculated the study-specific variables and performed analyses using aggregated variables such as sensitivity, specificity, prevalence, positive predictive value (PPV) and negative predictive value (NPV), and accuracy. RESULTS Five hundred and thirty eight patients were included in the analysis. The pretest probability for choledocholithiasis was 38.7. The mean sensitivity of EUS and MRCP for detection of choledocholithiasis was 93.7 and 83.5, respectively; the specificity was 88.5 and 91.5, respectively. Regarding EUS and MRCP, PPV was 89 and 87.8, respectively, and NPV was 96.9 and 87.8, respectively. The accuracy of EUS and MRCP was 93.3 and 89.7, respectively. CONCLUSIONS For the same pretest probability of choledocholithiasis, EUS has higher posttest probability when the result is positive and a lower posttest probability when the result is negative compared with MRCP.
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Affiliation(s)
| | - Eduardo G.H. Moura
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Dalton M. Chaves
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | | | - Sergio E. Matuguma
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
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Panzeri F, Crippa S, Castelli P, Aleotti F, Pucci A, Partelli S, Zamboni G, Falconi M. Management of ampullary neoplasms: A tailored approach between endoscopy and surgery. World J Gastroenterol 2015; 21:7970-7987. [PMID: 26185369 PMCID: PMC4499340 DOI: 10.3748/wjg.v21.i26.7970] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/27/2015] [Accepted: 05/04/2015] [Indexed: 02/07/2023] Open
Abstract
Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.
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Ahmad SR, Adler DG. Cancer of the ampulla of vater: current evaluation and therapy. Hosp Pract (1995) 2015; 42:45-61. [PMID: 25485917 DOI: 10.3810/hp.2014.12.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.
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Affiliation(s)
- Sarah R Ahmad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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Moulded calculus of common bile duct mimicking a stenosis. GASTROENTEROLOGY REVIEW 2014; 9:116-20. [PMID: 25061493 PMCID: PMC4108755 DOI: 10.5114/pg.2014.42508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/21/2011] [Accepted: 03/27/2012] [Indexed: 11/21/2022]
Abstract
Bile duct stenosis, in most cases, appears to be the consequence of pancreatic head, ampulla of Vater and bile duct tumours, cholangitis sclerosans, as well as iatrogenic damages, which may all be diagnosed during endoscopic retrograde cholangiopancreatography (ERCP). In very rare cases the restriction may result from an atypically shaped wedged stone. This situation creates many diagnostic problems, which in the majority of cases can be solved using imaging studies. However, in some patients even a significant extension of diagnostic procedures may not lead to a correct diagnosis. We present a diagnostically difficult case of a deposit imitating restriction. We present a 70-year-old woman with common bile duct restriction undiagnosed despite several ultrasound examinations (USG), computed tomography (CT), double magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). Only after the third ERCP examination a fragmented, by formerly introduced prosthesis, deposit, imitating narrowing, was revealed. Identification of bile duct deposits depends on their composition, localisation and the imaging techniques used. Pigment calculi with atypical shape, bile density, air density or surrounding tissue density are very difficult to diagnose. Thus, the sensitivity of common bile duct stone detection in USG, CT, MRCP and endoscopic ultrasound (EUS) is 5–88%; 6–88%; 73–97%; and 84–98%, respectively. Moreover, ERCP may not diagnose the character of the restriction even in 5.2% up to 30% of the patients. Consequently, assessment of diagnosis in a number of patients is difficult. A deposit imitating common bile duct (CBD) restriction is a rare, difficult to diagnose phenomenon, which should be taken into account during differential diagnosis of CBD restrictions.
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Caillol F, Bories E, Poizat F, Pesenti C, Esterni B, Monges G, Giovannini M. Endomicroscopy in bile duct: Inflammation interferes with pCLE applied in the bile duct: A prospective study of 54 patients. United European Gastroenterol J 2014; 1:120-7. [PMID: 24917949 DOI: 10.1177/2050640613483462] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 02/23/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The preoperative diagnosis of biliary stenosis is associated with low accuracy. As a consequence, probe-based confocal laser endomicroscopy (pCLE), an in-vivo histological imaging technique, was applied in the bile duct. The aim of this study was to establish whether previous inflammation of the bile duct affects confocal interpretation. The findings from pCLE were compared in two groups of patients: those in whom there had been no cholangitis nor stenting and those in whom stents had been used and subsequently retrieved or who had suffered cholangitis. PATIENTS AND METHODS pCLE was performed on 54 patients (mean age 66 years; 31 men, 23 women) from September 2008 to July 2011. Patients were divided in two groups: group 1: 39 patients who had not undergone a biliary procedure in the month preceding the pCLE procedure; and group 2: 15 patients who had undergone stent placement or presented with cholangitis in the month preceding the pCLE procedure. Endoscopic and pCLE data were collected prospectively. pCLE results were compared to benchmark histology (surgery, endoultrasonography, percutaneous biopsy). Patients with a benign stricture who did not undergo operation were followed for 1 year. pCLE images of the bile duct were obtained during endoscopic retrograde cholangiopancreatography procedures. pCLE images were interpreted prospectively using the Miami classification in vivo and in real time. RESULTS In group 1, sensitivity, specificity, and accuracy were 88, 83, and 87%, respectively. In group 2, sensitivity, specificity, and accuracy were 75, 71, and 73%, respectively. Diagnostic accuracy of pCLE was lower when applied to group 2 (p < 0,001). The investigation is less reliable in bile ducts affected by inflammation from cholangitis or previous stenting. CONCLUSIONS Inflammatory lesions of the bile duct interfere with interpretation of pCLE. A refined pCLE description of inflammatory lesions should improve accuracy of pCLE in bile duct stenosis.
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19
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For biliary dilatation, a negative endosonography needs additional image studies in weight loss suggesting malignancy. Dig Dis Sci 2013; 58:2345-52. [PMID: 23546699 DOI: 10.1007/s10620-013-2649-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/13/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM Biliary dilatation frequently raises concerns about the possibility of pancreatobiliary diseases. This study assessed the etiologic yield of endosonography (EUS) in this situation. METHODS A retrospective review was completed with 163 consecutive patients who had undergone EUS for a dilated common bile duct (CBD) without definite pathology on ultrasonography. RESULTS Binary logistic regression analysis disclosed that malignancy was positively related to weight loss and was inversely related to abdominal pain; nevertheless, choledocholithiasis was positively related to fever and elevated carbohydrate antigen 19-9 (p < 0.05). The accuracy of EUS was 95.1 % (155/163) for overall cause of biliary dilatation, 100 % (73/73) for no pathological finding, 96.3 % (26/27) for ampullary cancer, 84.6 % (11/13) for pancreatic cancer, 40.0 % (2/5) for CBD cancer, and 92.6 % (25/27) for choledocholithiasis, respectively. The accuracy of EUS decreased in the presence of malignancy (86.7 %, 39/45 vs. 98.3 %, 116/118, p = 0.006). EUS missed three CBD cancers, two pancreatic cancers, and one ampullary cancer; however, the diagnosis was rescued by computed tomography in two pancreatic cancers and one CBD cancer. CONCLUSIONS EUS is accurate in patients with fever suggestive of choledocholithiasis. However, a negative EUS finding should call for additional image studies in patients with weight loss suggestive of malignancy.
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Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi. Gastrointest Endosc Clin N Am 2013; 23:405-34. [PMID: 23540967 DOI: 10.1016/j.giec.2012.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.
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Shetty D, Bhatnagar G, Sidhu HS, Fox BM, Dodds NI. The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease. Clin Radiol 2013; 68:323-35. [PMID: 23391284 DOI: 10.1016/j.crad.2012.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/14/2012] [Accepted: 09/27/2012] [Indexed: 12/28/2022]
Abstract
Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.
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Affiliation(s)
- D Shetty
- Department of Clinical Radiology, Royal Cornwall Hospital, Truro, Cornwall, UK
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Zbar AP, Maor Y, Czerniak A. Imaging tumours of the ampulla of Vater. Surg Oncol 2012; 21:293-8. [DOI: 10.1016/j.suronc.2012.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/31/2012] [Accepted: 07/31/2012] [Indexed: 01/17/2023]
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Abstract
The causes of obstructive jaundice are varied, and timely, accurate methods of investigation are essential to avoid the development of complications. Imaging, invasive or non-invasive, should be carefully selected depending on the suspected underlying pathology in order to determine the degree and level of obstruction along with tissue acquisition and staging where relevant. Several imaging techniques will also allow subsequent therapeutic interventions to be carried out. This article reviews advances in the investigation of obstructive jaundice, highlighting recent developments, many of which at present remain restricted to large centres of expertise, but are likely to become more widespread in use as research progresses and local experience continues to improve.
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Affiliation(s)
- J Addley
- Department of Gastroenterology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK.
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Kanazawa K, Imazu H, Mori N, Ikeda K, Kakutani H, Sumiyama K, Hino S, Ang TL, Omar S, Tajiri H. A comparison of electronic radial and curvilinear endoscopic ultrasonography in the detection of pancreatic malignant tumor. Scand J Gastroenterol 2012; 47:1313-20. [PMID: 22943477 DOI: 10.3109/00365521.2012.719930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE There is no comparative study of electronic radial endoscopic ultrasonography (ER-EUS) and electronic curvilinear EUS (EC-EUS). The aim of this study was to compare the accuracy of ER-EUS and EC-EUS for detecting pancreatic malignancies. METHODS This was a retrospective review of the patients who had EUS assessment from September 2008 to December 2011 for suspicious pancreatic tumors. Sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancies were calculated and compared between the ER-EUS and EC-EUS cohort. The final diagnosis of pancreatic malignancy was based on pathology, or the consensus of patient's clinical course and multimodal imaging tests. RESULTS Two hundred twenty-one patients were included and divided into two cohorts: ER-EUS (n = 139) and EC-EUS (n = 82) cohorts. With propensity score matching method, 70 cases in each cohort were selected for the comparison. There was no significant difference in sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancy between ER-EUS and EC-EUS cohort (88.5 vs. 100%, 88.6 vs. 90.9%, 0.8855 vs. 0.9545). CONCLUSION ER-EUS and EC-EUS provided similar accuracy for the detection of pancreatic malignancies. In view of similar diagnostic results of ER-EUS and EC-EUS for the detection of pancreatic malignancy, and the advantage of being able to perform FNA with EC-EUS, EC-EUS may be the preferred choice.
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Affiliation(s)
- Keisuke Kanazawa
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
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Hall TC, Dennison AR, Garcea G. The diagnosis and management of Sphincter of Oddi dysfunction: a systematic review. Langenbecks Arch Surg 2012; 397:889-98. [PMID: 22688754 DOI: 10.1007/s00423-012-0971-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 05/31/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Sphincter of Oddi dysfunction (SOD) is a benign pathological syndrome. The clinical manifestations may be a consequence of an anatomical stenosis or sphincter dysmotility. Manometry is invasive and has an associated morbidity. Non-invasive investigations have been evaluated to ameliorate risk but have unknown efficacy. The review aims to critically appraise current evidence for the diagnosis and management of SOD. METHODS A systematic review of articles containing relevant search terms was performed. RESULTS Manometry is the current gold standard in selecting which patients are likely to benefit from endoscopic sphincterotomy (ES). It can, however, be misleading. Several non-invasive investigations were identified. These have poor sensitivities and specificities compared to manometry. There is a paucity of data examining the investigation's specific ability to select patients for ES. Outcomes of ES for Type I SOD are favourable irrespective of manometry. Types II and III SOD may respond to an initial trial of medical therapy. Manometry may predict response to ES in Type II SOD, but not in Type III. CONCLUSIONS Non-invasive investigations currently lack sufficient sensitivities and specificities for routine use in diagnosing SOD. Type I SOD should be treated with ES without manometry. Manometry may be useful for Type II SOD. However, whilst data is lacking a therapeutic trial of Botox(TM) or trial stenting may bean alternative. Careful and thorough patient counselling is essential. Type III SOD is associated with high complications from manometry and poor outcomes from ES. Alternative diagnoses should be thoroughly sought and its management should be medical.
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Affiliation(s)
- Thomas C Hall
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, UK.
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Tozzi di Angelo I, Prochazka V, Holinka M, Zapletalova J. Endosonography versus endoscopic retrograde cholangiopancreatography in diagnosing extrahepatic biliary obstruction. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 155:339-46. [PMID: 22336646 DOI: 10.5507/bp.2011.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Endosonography (EUS) performed prior to endoscopic retrograde cholangiopancreatography (ERCP) or surgery in patients with a low to moderate probability of choledocholithiasis can reduce morbidity, mortality and costs. AIMS This study aimed at evaluating the sensitivity and specificity of EUS and transabdominal ultrasonography (TUS) compared to ERCP in a cohort of 100 patients diagnosed with extrahepatic biliary obstruction. METHODS There were four working groups. The first group processed the initial data including history, physical examination and assessment of laboratory markers of cholestasis. The second group examined TUS. The third group examined the pancreas and biliary tree using EUS, always prior to ERCP. The fourth working group carried out ERCP. RESULTS The sensitivity and accuracy of EUS in the diagnosis of common bile duct dilatation were 84% and 83%, respectively, i.e. significantly higher (p=0.0001) than TUS (46% and 66%, respectively). The specificities of methods (82%, 91%) were not significantly different (p=0.218). The sensitivity and accuracy of EUS in the diagnosis of pathological content of the common bile duct were 88% and 92%, respectively, i.e. significantly higher (p<0.0001) than TUS (33% and 64%). The specificities of the methods (96%, 94%) were not significantly different (p=0.641). The incidence of choledocholithiasis in the high-risk group was significantly higher than in the moderate-risk group (p=0.012). CONCLUSION Radial EUS is a method with high sensitivity, specificity, positive and negative predictive values. It should therefore be preferred to ERCP in patients with low or moderate risk of choledocholithiasis.
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Affiliation(s)
- Igor Tozzi di Angelo
- Department of Internal Medicine II - Gastroenterology and Hepatology, University Hospital Olomouc, Czech Republic.
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Heinzow HS, Meister T, Domagk D. Endoskopische Papillenresektion: Indikation und Grenzen. Visc Med 2012. [DOI: 10.1159/000345869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Adenome der Papilla Vateri sind selten. Prävalenzen von 0,04–0,12% werden beschrieben. Eine maligne Transformation von benignen Adenomen zu Papillenkarzinomen ist möglich und folgt der Adenom-Karzinom-Sequenz. Die meisten Papillenadenome treten sporadisch auf, können jedoch z.B. bei Patienten mit familiärer adenomatöser Polyposis genetisch häufiger vorkommen. <b><i>Methode: </i></b>Es erfolgte eine aktuelle PubMed-Recherche zum Thema endoskopische Papillenresektion. <b><i>Ergebnisse/Schlussfolgerung: </i></b>Eine endoskopische Papillektomie kann bei Adenomen ohne duktale Infiltration durchgeführt werden, während es in Hinblick auf das papilläre Adenokarzinom noch keinen Konsens gibt. Jedoch konnten neuere Studien zeigen, dass Patienten mit hochgradiger intraepithelialer Neoplasie der Papilla Vateri keine lymphovaskuläre Invasion oder Lymphknotenmetastasen aufweisen, sodass eine endoskopische Papillektomie gerechtfertigt erscheint. Da papilläre Adenome in bis zu 30% der Fälle das Risiko für fokale karzinomatöse Areale beherbergen können, sollte jede Papillektomie «en bloc» durchgeführt werden.
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Benign biliary strictures: a current comprehensive clinical and imaging review. AJR Am J Roentgenol 2011; 197:W295-306. [PMID: 21785056 DOI: 10.2214/ajr.10.6002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. CONCLUSION Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.
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Giovannini M, Bories E, Monges G, Pesenti C, Caillol F, Delpero JR. Results of a phase I-II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis. Surg Endosc 2011; 25:2247-53. [PMID: 21424206 DOI: 10.1007/s00464-010-1542-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 11/16/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma). METHODS Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70 μm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection). RESULTS No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20 μm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20 μm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%. CONCLUSION This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.
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Affiliation(s)
- M Giovannini
- Endoscopic Unit, Paoli-Calmettes Institute, 232 Bd St-Marguerite, 13273, Marseilles cedex 9, France.
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Giovannini M, Bories E, Monges G, Pesenti C, Caillol F, Delpero JR. Results of a phase I-II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis. Surg Endosc 2011. [PMID: 21424206 DOI: 10.1007/s00464-010-1542-8d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma). METHODS Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70 μm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection). RESULTS No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20 μm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20 μm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%. CONCLUSION This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.
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Affiliation(s)
- M Giovannini
- Endoscopic Unit, Paoli-Calmettes Institute, 232 Bd St-Marguerite, 13273, Marseilles cedex 9, France.
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Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of "idiopathic" acute pancreatitis. Pancreas 2011; 40:289-94. [PMID: 21206330 DOI: 10.1097/mpa.0b013e318201654a] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The objectives of the study were to compare endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in the etiological diagnosis of patients initially diagnosed with idiopathic acute pancreatitis and to determine the clinical and analytical factors related to the end result of these techniques. METHODS Forty-nine patients, initially diagnosed with idiopathic acute pancreatitis, were evaluated prospectively with EUS and MRCP. Diagnoses were compared between the 2 procedures. The clinical-evolutionary characteristics of these patients with regard to the results obtained with these techniques were compared. RESULTS In twenty-eight patients (57%), EUS and/or MRCP diagnosed at least 1 possible cause of acute pancreatitis. The diagnostic yield of EUS was higher than that of MRCP (51% vs 20%; P = 0.001). Cholelithiasis and biliary sludge (24%) were the most frequent EUS diagnoses, and pancreas divisum (8%) was the most frequent MRCP diagnosis. Only in 3 cases (6%) did MRCP identify additional features in patients etiologically undiagnosed using EUS. The EUS yield was lower in patients who had a previous cholecystectomy (11% vs 60%; P = 0.008). CONCLUSIONS Endoscopic ultrasonography and MRCP are useful techniques in the etiological diagnosis of acute pancreatitis of nonestablished cause. Endoscopic ultrasonography should be preferred for establishing a possible biliary etiology in patients who have not had a cholecystectomy.
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Abstract
Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.
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Manta R, Conigliaro R, Castellani D, Messerotti A, Bertani H, Sabatino G, Vetruccio E, Losi L, Villanacci V, Bassotti G. Linear endoscopic ultrasonography vs magnetic resonance imaging in ampullary tumors. World J Gastroenterol 2010; 16:5592-5597. [PMID: 21105192 PMCID: PMC2992677 DOI: 10.3748/wjg.v16.i44.5592] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 05/04/2010] [Accepted: 05/11/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To assess linear endoscopic ultrasound (L-EUS) and magnetic resonance imaging (MRI) in biliary tract dilation and suspect small ampullary tumor. METHODS L-EUS and MRI data were compared in 24 patients with small ampullary tumors; all with subsequent histological confirmation. Data were collected prospectively and the accuracy of detection, histological characterization and N staging were assessed retrospectively using the results of surgical or endoscopic treatment as a benchmark. RESULTS A suspicion of ampullary tumor was present in 75% of MRI and all L-EUS examinations, with 80% agreement between EUS and histological findings at endoscopy. However, L-EUS and histological TN staging at surgery showed moderate agreement (κ = 0.54). CONCLUSION L-EUS could be a useful adjunct as a diagnostic tool in the evaluation of patients with suspected ampullary tumors.
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Palmucci S, Mauro LA, La Scola S, Incarbone S, Bonanno G, Milone P, Russo A, Ettorre GC. Magnetic resonance cholangiopancreatography and contrast-enhanced magnetic resonance cholangiopancreatography versus endoscopic ultrasonography in the diagnosis of extrahepatic biliary pathology. Radiol Med 2010; 115:732-46. [PMID: 20177983 DOI: 10.1007/s11547-010-0526-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 07/06/2009] [Indexed: 12/16/2022]
Abstract
PURPOSE This study compared the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) in evaluating the cause of extrahepatic bile duct dilatation. MATERIALS AND METHODS Forty-five patients (26 men, mean age 57 years) with extrahepatic biliary dilatation, as shown by transabdominal ultrasound, with or without elevated biliary and pancreatic serum indices, were prospectively studied with MRCP and EUS between September 2007 and October 2008. EUS and MRCP were performed within no more than 24 h of each other to reduce the possibility of changes due to stone migration. Image analysis was carried out in a double-blind fashion. RESULTS MRCP had 88.9% diagnostic accuracy, 91.9% sensitivity and 75% specificity, with 94.4% positive predictive value and 66.7% negative predictive value. EUS had 93.3% diagnostic accuracy, 97.3% sensitivity and 75% specificity; the positive and negative predictive values were 94.7% and 85.7%, respectively. CONCLUSIONS MRCP and EUS do not show significant statistical differences in diagnostic accuracy. MRCP is an accurate, noninvasive modality in the study of extrahepatic biliary pathology. EUS is especially reliable in patients with extrahepatic biliary obstruction caused by endoluminal sludge.
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Affiliation(s)
- S Palmucci
- Sezione di Scienze Radiologiche - Dipartimento Dogira, Azienda Ospedaliero Universitaria Policlinico - Vittorio Emanuele, Via Santa Sofia 78, Catania, Italy.
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Clinical feasibility of Açai (Euterpe olerácea) pulp as an oral contrast agent for magnetic resonance cholangiopancreatography. J Comput Assist Tomogr 2009; 33:666-71. [PMID: 19820489 DOI: 10.1097/rct.0b013e31819012a0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We evaluate the effectiveness of the Amazonian fruit pulp from Euterpe olerácea (popularly named Açaí) as a negative oral contrast agent applied to clinical routine. The use of such contrasts is particularly important in magnetic resonance cholangiopancreatography (MRCP) to reduce overlapping. MATERIALS AND METHODS We administered Açaí pulp to 5 nonsymptomatic subjects and 35 patients submitted to unspecific abdominal MR imaging, intending to set up optimal protocol. In 8 MRCP examinations, contrast and image effects were assessed and graded blindly by 2 independent radiologists. Quantitative analysis was performed by Wilcoxon test as to verify the potential of the Açaí to eliminate overlap signal over the pancreaticobiliary tract. Adverse effects and subject tolerance were also addressed. RESULTS The Açaí pulp elicited a local brightness decrease in T2-weighted images. The depiction of gallbladder, common bile duct, ampulla of Vater, and pancreatic duct was markedly improved after Açaí ingestion because of the suppression of the overlapping from bowel loops and gastric content (P < 0.01). All patients considered Açaí palatable, and no side effect was registered. CONCLUSIONS The Açaí pulp can be used routinely in MRCP studies as a natural, safe, and inexpensive negative oral contrast agent with high efficacy and patient acceptance.
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Deprez PH. [Clinical cases: what's new in biliopancreatic endoscopy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:266-271. [PMID: 19321280 DOI: 10.1016/j.gcb.2009.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- P-H Deprez
- Département de gastroentérologie, université catholique de Louvain, cliniques universitaires St-Luc, avenue Hippocrate-10, 1200 Bruxelles, Belgique.
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Chen CH, Yang CC, Yeh YH, Chou DA, Nien CK. Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. JOURNAL OF CLINICAL ULTRASOUND : JCU 2009; 37:18-25. [PMID: 18726967 DOI: 10.1002/jcu.20523] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE To reappraise the accuracy of transabdominal sonography (US), CT, MRI, and endosonography (EUS) in the diagnosis and staging of ampullary tumors. METHOD We reviewed the medical records and the images of 41 consecutive patients with ampullary tumors. Tumor detection rate and accuracy of TNM (tumor-node-metastasis) staging of malignant tumors were determined. Imaging findings were correlated with histopathologic findings. RESULTS The detection rates for ampullary tumors were 97.6% for EUS, 81.3% for MRI, 28.6% for CT, and 12.2% for US (p < 0.001 for EUS versus CT; p < 0.001 for EUS versus US; p > 0.05 for EUS versus MRI). The accuracy in T staging for ampullary carcinomas was 72.7% for EUS, 53.8% for MRI, and 26.1% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI). The accuracy in N staging for ampullary carcinomas was 66.7% for EUS, 76.9% for MRI, and 43.5% for CT with no statistically significant difference between the 3 modalities. The sensitivity in detecting malignant lymph nodes was 46.7% for EUS, 25.0% for MRI, and 0% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI; p > 0.05 for MRI versus CT). Transpapillary stenting, advanced tumor extension (>T2), large tumor size (>2 cm), tumor differentiation, and endoscopic appearance of tumor growth did not significantly influence EUS accuracy in T or N staging (p > 0.05). CONCLUSION EUS was superior to CT and was equivalent to MRI for tumor detection and T and N staging of ampullary tumors. Neither indwelling stents nor tumor size, differentiation, or endoscopic appearance affected the staging accuracy of EUS.
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Affiliation(s)
- Chien-Hua Chen
- Digestive Disease Center, Changhua Show-Chwan Memorial Hospital, Changhua 500, Taiwan
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Săftoiu A, Vilmann P. Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. JOURNAL OF CLINICAL ULTRASOUND : JCU 2009; 37:1-17. [PMID: 18932265 DOI: 10.1002/jcu.20534] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.
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Affiliation(s)
- Adrian Săftoiu
- Department of Gastroenterology, University of Medicine and Pharmacy Craiova, Craiova, Dolj, 200490, Romania
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Bessa SS, Al-Fayoumi TA, Katri KM, Awad AT. Clipless laparoscopic cholecystectomy by ultrasonic dissection. J Laparoendosc Adv Surg Tech A 2008; 18:593-8. [PMID: 18721011 DOI: 10.1089/lap.2007.0227] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Ultrasonically activated devices have been used in gallbladder dissection in the laparoscopic cholecystectomy with encouraging results. The aim of this study was to compare between the safety and efficacy of the harmonic shears and the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. METHODS In this prospective study, 120 patients with symptomatic gallstone disease were randomly assigned to either the harmonic scalpel laparoscopic cholecystectomy group (HS group=60 patients) where closure and division of the cystic duct was achieved solely by the harmonic shears or the clip and cautery laparoscopic cholecystectomy group (C&C group=60 patients). RESULTS Neither minor nor major bile leaks were encountered in either group. Similarly, no bile-duct injuries were encountered in the present study. The incidence of gallbladder perforation was statistically significantly higher in the C&C group, compared to the HS group (30 vs. 10%, respectively; P=0.002). The median operative time was statistically significantly shorter in the HS group than in the C&C group (32 vs. 40 minutes, respectively; P=0.000). No statistically significant difference was found in the incidence of postoperative complications between both groups. CONCLUSIONS The harmonic shears are as safe and effective as the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. Further, it provides a superior alternative to the currently used high-frequency monopolar technology in terms of shorter operative time and lower incidence of gallbladder perforation.
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Affiliation(s)
- Samer S Bessa
- Department of General Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
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Janssen J, Halboos A, Greiner L. EUS accurately predicts the need for therapeutic ERCP in patients with a low probability of biliary obstruction. Gastrointest Endosc 2008; 68:470-6. [PMID: 18547571 DOI: 10.1016/j.gie.2008.02.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 02/15/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Because of its inherent risks, ERCP should only be performed for purposes of treatment. EUS and MRCP have emerged as diagnostic alternatives before therapeutic ERCP. OBJECTIVE Our purpose was to test the accuracy of EUS in predicting the need for therapeutic ERCP in low-risk patients. DESIGN Prospective, unblinded, single-center study. SETTING Academic center of the University of Witten/Herdecke. PATIENTS Fifty patients with clinical, laboratory, or transabdominal US findings suggestive of biliary obstruction were included. INTERVENTIONS After clinical assessment and US, all patients underwent EUS. If EUS was conclusive, either ERCP with sphincterotomy (EST) was performed or the patients were followed up for 1 year. If EUS was inconclusive, MRCP was performed, followed by ERCP or a 1-year follow-up. After each diagnostic step, the examiner decided whether any biliary conditon was present and whether therapeutic ERCP was necessary. The decicions were compared with the results of ERCP with EST or the outcome after the 1-year follow-up. MAIN OUTCOME MEASUREMENTS Accuracy of EUS in predicting the need for therapeutic ERCP. RESULTS Nine patients had ERCP with EST. The final assessment classified 2 of these interventions as having been unnecessary. EUS was conclusive in 49 cases. After EUS, the accuracy of the decision on the presence of a biliary condition increased from 82% to 96% and on the need for therapeutic ERCP from 86% to 96%. LIMITATION Single-center experience. CONCLUSION EUS accurately predicts the need for therapeutic ERCP in patients at low risk for biliary obstruction.
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Affiliation(s)
- Jan Janssen
- Second Department of Medicine, HELIOS Klinikum Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
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Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008; 67:235-44. [PMID: 18226685 DOI: 10.1016/j.gie.2007.09.047] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 09/20/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS has been proposed as a less invasive means of diagnosing choledocholithiasis and may eliminate the need for ERCP and its associated risks. The literature pertaining to EUS for the diagnosis of choledocholithiasis reports widely varying sensitivities and specificities. OBJECTIVE To more precisely estimate the diagnostic accuracy of EUS in suspected choledocholithiasis. DESIGN MEDLINE and EMBASE databases were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable criterion standard, including ERCP, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality. A random effects model was used to estimate the sensitivity, specificity, likelihood, and diagnostic odds ratio (DOR), and a summary receiver operating characteristic curve was constructed. All predefined potential sources of heterogeneity were explored by subgroup analysis and meta-regression. PATIENTS A total of 2673 patients with suspected choledocholithiasis were reported in 27 studies that satisfied the inclusion criteria. RESULTS EUS had a high overall pooled sensitivity of 0.94 (95% CI, 0.93-0.96), a specificity of 0.95 (95% CI, 0.94-0.96), and an area under the curve of 0.98. Three variables appeared to yield a higher DOR: a higher disease prevalence, an adequate time interval between index test and criterion standards, and the presence of verification bias. LIMITATIONS Misclassification of patients by imperfect criterion standards could potentially underestimate the performance of an EUS. CONCLUSIONS An EUS is a noninvasive test, with excellent overall sensitivity and specificity for diagnosing choledocholithiasis. An EUS should, therefore, be used to select patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP.
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Affiliation(s)
- Frances Tse
- Division of Gastroenterology, McMaster University Medical Centre, McMaster University, Hamilton, Ontario, Canada
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McMahon CJ. The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound in diagnosis of common bile duct calculi: a critically appraised topic. ACTA ACUST UNITED AC 2008; 33:6-9. [PMID: 17874159 DOI: 10.1007/s00261-007-9304-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) in the investigation of common bile duct (CD) calculi were evaluated using "evidence-based practice" (EBP) methods. METHODS A focused clinical question was constructed. A structured search of primary and secondary evidence was performed. Retrieved studies were appraised for validity, strength and level of evidence (Oxford/CEBM scale: 1-5). Retrieved literature was divided into group A; MRCP slice thickness >or=5 mm, group B; MRCP slice thickness = 3 mm or 3D-MRCP sequences. RESULTS Six studies were eligible for inclusion (3 = level 1b, 3 = level 3b). Group A: sensitivity and specificity of MRCP and EUS were (40%, 96%) and (80%, 95%), respectively. Group B: sensitivity and specificity of MRCP and EUS were (87%, 95%) and (90%, 99%), respectively. CONCLUSION MRCP should be the first-line investigation for CD calculi and EUS should be performed when MRCP is negative in patients with moderate or high pre-test probability.
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Affiliation(s)
- Colm J McMahon
- Department of Radiology, St. Vincent's University Hospital, Dublin 4, Ireland.
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Abstract
Cholangiocarcinoma is suspected based on signs of biliary obstruction, abnormal liver function tests, elevated tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen), and ultrasonography showing a bile stricture or a mass, especially in intrahepatic cholangiocarcinoma. Magnetic resonance imaging (MRI) or computed tomography (CT) is performed for the diagnosis and staging of cholangiocarcinomas. However, differentiation of an intraductal cholangiocarcinoma from a hypovascular metastasis is limited at imaging. Therefore, reasonable exclusion of an extrahepatic primary tumor should be performed. Differentiating between benign and malignant bile duct stricture is also difficult, except when metastases are observed. The sensitivity of fluorodeoxyglucose positron emission tomography is limited in small, infiltrative, and mucinous cholangiocarcinomas. When the diagnosis of a biliary stenosis remains indeterminate at MRI or CT, endoscopic imaging (endoscopic or intraductal ultrasound, cholangioscopy, or optical coherence tomography) and tissue sampling should be carried out. Tissue sampling has a high specificity for diagnosing malignant biliary strictures, but sensitivity is low. The diagnosis of cholangiocarcinoma is particularly challenging in patients with primary sclerosing cholangitis. These patients should be followed with yearly tumor markers, CT, or MRI. In the case of dominant stricture, histological or cytological confirmation of cholangiocarcinoma should be obtained. More studies are needed to compare the accuracy of the various imaging methods, especially the new intraductal methods, and the imaging features of malignancy should be standardized.
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Affiliation(s)
- B E Van Beers
- Diagnostic Radiology Unit, Université Catholique de Louvain, St-Luc University Hospital, Brussels, Belgium.
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Ledro-Cano D. Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review. Eur J Gastroenterol Hepatol 2007; 19:1007-11. [PMID: 18049172 DOI: 10.1097/meg.0b013e328133f30b] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is a lack of consensus on the optimal noninvasive strategy for patients with suspected choledocholithiasis after a negative transabdominal ultrasound and/or computed tomography. A meta-analysis was conducted to compare the diagnostic ability of endoscopic ultrasound (EUS) and magnetic resonance cholangio-pancreatography (MRCP) in patients with suspected common bile duct (CBD) stones. A search, using the following terms 'MRCP', 'EUS' and 'Choledocholithiasis' in Pubmed and Cochrane Controlled Trials Register, was performed. Abstract books and reference list of review articles, as well as relevant studies, were also searched to complete our EUS versus MRCP for choledocholithiasis comparison studies database. The analysis demonstrated that, with respect to sensitivity, specificity and accuracy, there was no statistically significant difference between EUS and MRCP for the detection of choledocholithiasis. Our meta-analysis of prospective comparison of MRCP and EUS for the detection of choledocholithiasis yielded statistically similar diagnostic values for both techniques.
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McMahon CJ. The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound in diagnosis of malignant common bile duct strictures: a critically appraised topic. ACTA ACUST UNITED AC 2007; 33:10-3. [PMID: 17874158 DOI: 10.1007/s00261-007-9305-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) in the investigation of malignant common bile duct (CD) strictures were evaluated using "evidence-based practice" (EBP) methodology. METHODS A focused clinical question was constructed. A structured search of primary and secondary evidence was performed. Retrieved studies were appraised for validity, strength and level of evidence (Oxford/CEBM scale: 1-5). RESULTS Three studies were eligible for inclusion; there were 2 level 3b and 1 level 4 papers. One paper included a patient group appropriate to the question and contained sufficient data to allow analysis. Sensitivity and specificity of MRCP and EUS were (90%, 65%) and (80%, 80%), respectively. CONCLUSION In the diagnosis of malignant CD strictures, EUS is more specific than MRCP and may allow cytology to be obtained via a trans-duodenal approach. A multi modality imaging approach is recommended.
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Affiliation(s)
- Colm J McMahon
- Department of Diagnostic Imaging, St. James Hospital, Dublin 8, Ireland,
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Gan SI, Rajan E, Adler DG, Baron TH, Anderson MA, Cash BD, Davila RE, Dominitz JA, Harrison ME, Ikenberry SO, Lichtenstein D, Qureshi W, Shen B, Zuckerman M, Fanelli RD, Lee KK, Van Guilder T. Role of EUS. Gastrointest Endosc 2007; 66:425-34. [PMID: 17643438 DOI: 10.1016/j.gie.2007.05.026] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fernández-Esparrach G, Ginès A, Sánchez M, Pagés M, Pellisé M, Fernández-Cruz L, López-Boado MA, Quintó L, Navarro S, Sendino O, Cárdenas A, Ayuso C, Bordas JM, Llach J, Castells A. Comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of pancreatobiliary diseases: a prospective study. Am J Gastroenterol 2007; 102:1632-1639. [PMID: 17521400 DOI: 10.1111/j.1572-0241.2007.01333.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To compare the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in: (a) patients with a dilated biliary tree unexplained by ultrasonography (US) (group 1), and (b) the diagnosis of choledocholithiasis in patients with nondilated biliary tree (group 2). METHODS Patients were prospectively evaluated with EUS and MRCP. The gold standard used was surgery or EUS-FNA and ERCP, intraoperative cholangiography, or follow-up when EUS and/or MRCP disclosed or precluded malignancy, respectively. Likelihood ratios (LR) and pretest and post-test probabilities for the diagnosis of malignancy and choledocholithiasis were calculated. RESULTS A total of 159 patients met one of the inclusion criteria but 24 of them were excluded for different reasons. Thus, 135 patients constitute the study population. The most frequent diagnosis was choledocholithiasis (49% in group 1 and 42% in group 2, P= 0.380) and malignancy was more frequent in group 1 (35%vs 7%, respectively, P < 0.001). When EUS and MRCP diagnosed malignancy, its prevalence in our series (35%) increased up to 98% and 96%, respectively, whereas it decreased to 0% and 2.6% when EUS and MRCP precluded this diagnosis. In patients in group 2, when EUS and MRCP made a positive diagnosis of choledocholithiasis, its prevalence (42%) increased up to 78% and 92%, respectively, whereas it decreased to 6% and 9% when any pathologic finding was ruled out. CONCLUSIONS EUS and MRCP are extremely useful in diagnosing or excluding malignancy and choledocholithiasis in patients with dilated and nondilated biliary tree. Therefore, they are critical in the approach to the management of these patients.
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Affiliation(s)
- Glòria Fernández-Esparrach
- Gastroenterology Department, Institut de Malalties Digestives i Metabòliques, CIBER HEPAD, University of Barcelona, Barcelona, Spain
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Garrow D, Miller S, Sinha D, Conway J, Hoffman BJ, Hawes RH, Romagnuolo J. Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007; 5:616-23. [PMID: 17478348 DOI: 10.1016/j.cgh.2007.02.027] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound (EUS) achieves high-resolution images of the bile duct and pancreas, while avoiding the risks of ERCP (endoscopic retrograde cholangiopancreatography). It appears comparable to MRCP (magnetic resonance cholangiopancreatography), although its use is less widely disseminated. We aimed to summarize EUS test performance in suspected biliary disease with meta-analysis. METHODS MEDLINE search (January 1987-September 2006), selected reference lists, external experts, and manual search of abstracts were used. Studies permitting (re)construction of 2 x 2 tables for EUS versus a gold standard were used. Random-effects models were used to estimate pooled sensitivity and specificity after adjusting for a number of potential confounders. Summary receiver operating characteristic analysis, with the sensitivity corresponding to the point on the receiver operating characteristic curve where sensitivity equals specificity (Q*) and area under the curve, was performed. The effects of sample size, quality, disease prevalence and spectrum, pancreatitis, echoendoscope type, and EUS era on diagnostic performance were assessed. Performance regarding presence of obstruction, choledocholithiasis, and malignancy was analyzed. RESULTS Thirty-six eligible, non-overlapping studies met inclusion criteria (3532 subjects). EUS had a high overall pooled sensitivity (88%; 95% confidence interval, 85%-91%) and specificity (90%; 87%-93%) for biliary obstruction (area under the curve = 0.97; Q* = 0.92). EUS had higher sensitivity (89%; 87%-91%) and specificity (94%; 91%-96%) for choledocholithiasis than for malignancy (sensitivity, 78%; 69%-85%; specificity, 84%; 78%-91%). Smaller studies and ones mainly studying patients with suspected strictures were associated with lower test performance. CONCLUSIONS There is excellent overall accuracy for EUS in diagnosing choledocholithiasis, with less impressive results for malignancy (when fine-needle aspiration is not used).
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Affiliation(s)
- Donald Garrow
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Pirro N, Racaud M, Jouffret-Leseigneur C, Agostini S, Sastre B, Di Marino V. Assessment of the main pancreatic duct using computed tomography with multiplanar reconstructions. Morphologie 2007; 90:151-6. [PMID: 17278454 DOI: 10.1016/s1286-0115(06)74496-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED The aim of this study was to assess the morphology of the main pancreatic duct (MPD) using multiplanar reconstructions and to compare this with the morphology of the MPD of anatomic subjects. MATERIALS AND METHODS The morphology of the MPD was studied by means of multiplanar reconstructions obtained on the one hand from thin tomodensitometric slices and on the other hand from the dissection of anatomic subjects. This study involved 15 subjects in each group. RESULTS Full multiplanar reconstruction was obtained in 13 cases. In 2 cases, the isthmus did not appear in the reconstructions. The morphology of the MPD was similar in both groups. The length of the MPD was identical at the head and isthmus of the pancreas in both groups but was greater in the dissection group than in the reconstruction group in the body and tail areas of the pancreas. The diameter of the MPD was greater at the head of the pancreas in the dissection group and was identical in both groups for the other segments of the MPD. CONCLUSIONS Multiplanar tomodensitometric reconstruction of the main pancreatic duct is feasible. This new technique, currently under evaluation, could allow the study of canalar pathologies of the pancreas through tomodensitometry.
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Affiliation(s)
- N Pirro
- Department of Anatomy, Faculté de Médecine de Marseille, Secteur Timone, 27 Bd Jean Moulin, 13385 Marseille Cedex 05.
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Sgouros SN, Bergele C. Endoscopic ultrasonography versus other diagnostic modalities in the diagnosis of choledocholithiasis. Dig Dis Sci 2006; 51:2280-6. [PMID: 17080253 DOI: 10.1007/s10620-006-9218-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Accepted: 12/23/2005] [Indexed: 12/09/2022]
Abstract
Until recently, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for the diagnosis of and therapy in patients with suspected choledocholithiasis. However, the non-negligible complication rate of diagnostic and therapeutic ERCP has led investigators to identify different noninvasive diagnostic modalities. Endoscopic ultrasonography has been proved to be of great sensitivity (up to 97%) in the diagnosis of even tiny stones that can be easily masked by contrast medium during ERCP, without any procedure-related complications and with a negative predictive value reaching 100%, meaning that it can accurately and safely identify patients with choledocholithiasis, thereby avoiding inappropriate instrumental exploration of the common bile duct.
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Affiliation(s)
- Spiros N Sgouros
- Department of Gastroenterology, Athens Naval and Veterans Hospital, Nafpaktias 5, Agia Paraskevi, 15341, Athens, Greece.
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