Recognizing intrapancreatic accessory spleen via EUS: Interobserver variability.

BACKGROUND AND OBJECTIVE: Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions. MATERIALS AND METHODS: Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15. RESULTS: In our sample, the interobserver agreement was 0.37 (-+1-1; 0-0.2 poor, 0.2-0.4 fair, 0.4-0.6 moderate, 0.6-0.8 substantial, and 0.8-1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively. CONCLUSION: There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.

Variation in polyp size estimation among endoscopists and impact on surveillance intervals.

BACKGROUND: Accurate estimation of polyp size is important because it is used to determine the surveillance interval after polypectomy. OBJECTIVE: To evaluate the variation and accuracy in polyp size estimation among endoscopists and the impact on surveillance intervals after polypectomy. DESIGN: Web-based survey. PARTICIPANTS: A total of 873 members of the American Society for Gastrointestinal Endoscopy. INTERVENTIONS: Participants watched video recordings of 4 polypectomies and were asked to estimate the polyp sizes. MAIN OUTCOME MEASUREMENTS: Proportion of participants with polyp size estimates within 20% of the correct measurement and the frequency of incorrect surveillance intervals based on inaccurate size estimates. RESULTS: Polyp size estimates were within 20% of the correct value for 1362 (48%) of 2812 estimates (range 39%-59% for the 4 polyps). Polyp size was overestimated by >20% in 889 estimates (32%, range 15%-49%) and underestimated by >20% in 561 (20%, range 4%-46%) estimates. Incorrect surveillance intervals because of overestimation or underestimation occurred in 272 (10%) of the 2812 estimates (range 5%-14%). Participants in a private practice setting overestimated the size of 3 or of all 4 polyps by >20% more often than participants in an academic setting (difference = 7%; 95% confidence interval, 1%-11%). LIMITATIONS: Survey design with the use of video clips. CONCLUSION: Substantial overestimation and underestimation of polyp size occurs with visual estimation leading to incorrect surveillance intervals in 10% of cases. Our findings support routine use of measurement tools to improve polyp size estimates.

Gastrojejunal stricture after gastric bypass and efficacy of endoscopic intervention.

The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52-77], and negative predictive value (NPV) of 83% (95% CI 65-93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.