Endoscopic position control of nasoenteral feeding tubes by transnasal re-endoscopy: a prospective study in intensive care patients.

OBJECTIVES: In critically ill patients, correct placement of enteral feeding tubes is usually controlled by X-ray. A bedside method without radiation exposure would be preferable. This study aimed to demonstrate the feasibility and value of endoscopic position control for enteral feeding tubes by transnasal re-endoscopy. METHODS: A total of 120 consecutive examinations in critically ill patients were analyzed. Immediately after transnasal endoscopic placement of a feeding tube, the correct position was determined by re-endoscopy. In cases of incorrect position, replacement was performed instantly until the correct position was achieved. Abdominal X-ray with contrast was performed thereafter and served as the gold standard. RESULTS: In 95 patients (79%), endoscopic control showed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (one attempt in 22 patients, two attempts in 3 patients). Radiological control showed correct position in 118 patients (98%). In two cases, the feeding tube was displaced in the meantime. The sensitivity and positive predictive value of endoscopic position control was 100% (95% confidence interval, CI; 97-100%) and 98% (95% CI; 94-99%), respectively. The cost savings per case ranged from $281 to $302, depending on different cost assumptions. CONCLUSIONS: Endoscopic position control of enteral feeding tubes by re-endoscopy is feasible, very accurate, leads to a high rate of successful feeding tube placements, and has the potential of substantial cost-savings.

Intraoperative sonography in patients with colorectal cancer and resectable liver metastases on preoperative FDG-PET-CT.

BACKGROUND: Combined fluorine 18-fluorodeoxyglucose-positron emission tomography-CT imaging has been shown to be of good diagnostic value in the preoperative evaluation of patients with colorectal cancer and liver metastases. The adjunctive use of intraoperative sonography (IOUS) may have a limited impact on treatment selection in these patients. PURPOSE: To compare the diagnostic performance of preoperative positron emission tomography (PET)-CT alone and PET-CT combined with IOUS in the evaluation of patients who are considered for curative resection of hepatic metastases from colorectal carcinoma. MATERIALS AND METHODS: Patients with colorectal cancer who underwent resection of hepatic metastases and preoperative PET-CT (with or without contrast-enhanced CT) and IOUS were identified. The performance of the imaging techniques was evaluated through review of the radiologic reports, correlation with surgical and histopathologic findings, and clinical follow-up. RESULTS: Thirty-one patients (mean age, 63.5 years [range, 53-82 years]) were analyzed. Fifteen patients had received preoperative chemotherapy. The mean interval between PET-CT and IOUS was 22.6 days (range, 1-56 days). In 4 cases, neither PET-CT nor IOUS correctly diagnosed the liver metastases. In all 31 patients, the sensitivity of PET-CT alone and PET-CT combined with IOUS was 63% (95% CI 44-80%) and 93% (95% CI 78-98%), respectively; the positive predictive value was 81% and 89%, respectively. In patients without preoperative chemotherapy (n = 16), the sensitivity of PET-CT alone and PET-CT combined with IOUS was 77% (95% CI 49-94%) and 100% (95% CI 79-100%), respectively. In 11 cases (35%), IOUS altered the surgical strategy. CONCLUSION: In patients with colorectal carcinoma and potentially resectable liver metastases on preoperative PET-CT, IOUS can provide additional information that may alter decision making with regard to surgical technique.

Transnasal endoscopy for the placement of nasoenteral feeding tubes: does the working length of the endoscope matter?

BACKGROUND: Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. OBJECTIVE: To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. DESIGN: Randomized controlled study. SETTING: University Hospital of Zurich, Switzerland. PATIENTS: Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. MAIN OUTCOME MEASUREMENTS: Success rates of endoscopic placement of enteral feeding tubes. RESULTS: A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001). LIMITATIONS: In rare cases, the randomization list could not be followed correctly. CONCLUSIONS: This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy.

BACKGROUND AND AIMS: There is growing evidence that gastroesophageal reflux disease (GERD) may cause typical laryngeal/pharyngeal lesions secondary to tissue irritation. The prevalence of those lesions in GERD patients is not well established. The aim of this study was to evaluate the prevalence of GERD signs in the laryngopharyngeal area during routine upper gastrointestinal endoscopy. METHODS: Between July 2000 and July 2001, 1,209 patients underwent 1,311 upper gastrointestinal endoscopies and were enrolled in this study. The structured examination of the laryngopharyngeal area during upper gastrointestinal endoscopy was videotaped for review by three gastroenterologists and one otorhinolaryngologist, blinded to the endoscopic esophageal findings. From the 1,209 patients enrolled in this prospective study, all patients (group I, N = 132) with typical endoscopical esophageal findings of GERD (Savary-Miller I-IV) were selected. The sex- and age-matched control group II (N = 132) underwent upper gastrointestinal endoscopy for different reasons, had no reflux symptoms, and had normal esophagoscopy. RESULTS: In the two groups of patients, we found no difference in the prevalence of abnormal interarytenoid bar findings (32%vs 32%), arytenoid medial wall erythema (47%vs 43%), posterior commissure changes (36%vs 34%), or posterior cricoid wall edema (1%vs 3%). The only difference was noted in the posterior pharyngeal wall cobblestoning (66%vs 50%, P= 0.004). CONCLUSION: The results of this large systematic investigation challenge the diagnostic specificity of laryngopharyngeal findings attributed to gastroesophageal reflux.

Granular cell tumor of the biliary system: a report of 2 cases with cytologic diagnosis on endoscopic brushing.

BACKGROUND: Granular cell tumors (GCTs) of biliary system are rare. GCTs show a striking preponderance for young, black females, who generally present with obstructive jaundice. To our knowledge, these are the first 2 reports of GCT of biliary system identifed on endoscopic brushing cytology. CASES: In case 1, a 24-year-old, black woman presented with a 5-month history of pruritus. Radiographic studies demonstrated a mass in the distal common bile duct. Endoscopic biopsy and bile duct brushing were diagnosed as GCT. A Whipple procedure was confirmatory of GCT. In case 2, a 38-year-old, black female presented with a 7-month history of pruritus and jaundice. Radiographic studies showed a stricture of the common hepatic duct at the hilum. Endoscopic brushing cytology of the stricture yielded only a few sheets of granular cells that were missed on initial screening. Suspicion of cholangiocarcinoma prompted surgery, and final histopathology showed GCT. Both patients were well 1 1/2 and 6 years after presentation. CONCLUSION: GCT of the bile duct can be diagnosed on endoscopic brushing and should be considered in the cytologic differential diagnosis in the appropriate clinical settings.

The influence of rapid food intake on postprandial reflux: studies in healthy volunteers.

BACKGROUND: The postprandial increase of gastroesophageal reflux (GER) results largely from an increase in the rate of transient lower esophageal sphincter relaxations (TLESRs). Gastric distension is believed to be the most important contributing factor. The aim of this study was to determine the impact of rapid food intake on GER in healthy volunteers using combined multichannel intraluminal impedance and pH (MII-pH) testing to record both acid and nonacid reflux. Our hypothesis was that rapid food intake overstresses the gastric pressure-volume response and contributes to increased postprandial GER. METHODS: Twenty healthy volunteers were included in the study. On two separate days the participants were asked to eat the same standard meal within 5 or 30 min in random order. Acid and nonacid reflux episodes were recorded over a 2-h postprandial period. RESULTS: Intake of a standard meal within 5 min was associated with more reflux episodes (median = 14) than an intake within 30 min (median = 10, p= 0.021). The increase was confined to the first postprandial hour and was caused predominantly by an increase of nonacid reflux. During the entire 2-h postprandial period, 469 reflux episodes were noted in the 40 studies. During the first postprandial hour 45% (135/303) of reflux events were nonacid as opposed to 22% (37/166) noted during the second hour (p < 0.0001). CONCLUSION: Since rapid food intake produces more GER in healthy volunteers, studies in GERD patients are warranted to evaluate if eating slowly may represent another "life-style modification" aimed at reducing GER.

Assessment of health state utilities and quality of life in patients with malignant esophageal Dysphagia.

OBJECTIVES: Palliation of terminal conditions such as malignant dysphagia must take into account individual preferences for aggressive or nonaggressive care, with a focus on quality of life. Despite this, there are very few data on patients' preferences for palliative therapy. This study is designed to quantitatively determine individual preferences for palliation of malignant dysphagia using health state utilities (HSU). METHODS: HSU were measured using three methods: time trade-off (TTO), visual analog scale (VAS), and the EQ-5D. Patients with esophageal cancer were asked to rate their own state of health and of three standardized scenarios of local, regional, and metastatic disease. RESULTS: Fifty patients with esophageal cancer were enrolled. Using the TTO method, the utilities of their own health state were 0.80 (95% CI 0.59-0.99) for localized, 0.54 (0.37-0.70) for regional, and 0.52 (0.32-0.71) for metastatic cancer showing no significant difference in mean utility scores for the three staging groups. VAS and EQ5D gave statistically similar values to TTO. Patients consistently rated their own utility better than the utility of standardized scenarios with similar stage and prognosis. Independent of their staging, patients with high dysphagia scores rated their utility worse than patients with low dysphagia scores. CONCLUSIONS: These results confirm the perceived poor state of health of patients with esophageal cancer and are substantially lower than previous estimates in operated patients. Cost-effectiveness models must take into account significant differences between patients' assessment of their own state of health, and that of a "societal" perspective of others with a similar disease. All three methods provided similar estimates. Given the ease of use of VAS and EQ-5D, these methods may be preferable to TTO.

Accuracy of EUS in staging of T4 lung cancer.

BACKGROUND: Increasingly, EUS is being used to stage lung cancer. Direct mediastinal invasion (T4) by lung cancer is stage IIIb disease. Patients in this stage have a 5-year survival of less than 5% and generally are offered chemotherapy without surgery. This study evaluated the accuracy of EUS in detecting T4 lung cancer. METHODS: The study included all patients with lung cancer who had EUS staging and subsequent staging at surgery, or for whom there was unequivocal confirmation of unresectability (T4) by thoracoscopy, thoracotomy or presence of malignant pleural effusion, or definite invasion of great vessels/adjacent organs on CT. RESULTS: A total of 175 of 308 patients with lung cancer who underwent EUS over a 5-year period (1997-2002) had subsequent confirmatory tumor staging. Ten patients were found by EUS to have stage T4 tumors; 7 were confirmed to be T4 by either surgical exploration (2), CT demonstration of aortic invasion (3), or documentation of malignant pleural effusion (2). Three of the 10 (30%) patients found to have stage T4 tumors by EUS had T2 disease at surgery and underwent curative resection. Of the remaining 165 patients without evidence of T4 disease at EUS, only one was found to have aortic invasion (T4) at surgery. EUS had a sensitivity of 87.5%, specificity of 98%, positive predictive value of 70%, and a negative predictive value of 99% for detecting T4 disease. CONCLUSIONS: Caution is warranted when unresectability of lung cancer is based solely on tumor invasion into mediastinal soft tissue at EUS. Overstaging occurs when a tumor appears to invade the pleural layer without mediastinal organ invasion. Confirmation of unresectability by other diagnostic modalities is warranted in such instances.

Is esophagoscopy alone sufficient for patients with reflux symptoms?

BACKGROUND: Unsedated esophagoscopy with ultrathin endoscopes is a valuable screening modality for Barrett's esophagus, but the stomach and the duodenum cannot be examined completely with the smallest and best tolerated of these endoscopes. There are no data as to how often disease in the stomach and the duodenum would be missed when using this screening strategy. Our hypothesis is that patients with reflux symptoms, in the absence of daily abdominal pain, nausea, or history of ulcer, were unlikely to have clinically significant gastroduodenal disease. METHODS: Patients scheduled for upper endoscopy at a single outpatient endoscopy unit in a tertiary referral center were screened. The inclusion criterion was reflux symptoms as the primary indication for upper endoscopy. Patients with another valid indication were excluded. A detailed history was recorded and symptom questionnaire completed for each patient before endoscopy; these data were compared with the endoscopy findings. RESULTS: A total of 175 patients were included. Indications for upper endoscopy were the following: worsening symptoms (n=74), ongoing reflux despite therapy (n=27), and long-standing reflux (n=74). Major esophageal findings were discovered in 95 patients. In 10 patients, major gastric or duodenal findings were detected as follows: erosive gastritis (n=8), gastric ulcer (n=2), duodenal ulcer (n=2), erosive duodenitis (n=2), and duodenal polyp (n=1). Daily abdominal pain (p=0.014) or possibly daily nausea (p=0.028 unadjusted, 0.197 adjusted) was associated with major gastric/duodenal disease. Patients without daily abdominal pain, nausea, or a history of gastric/duodenal ulcer were much less likely to have major disease (0.9%) than patients with one of these predictors (13.2%, p=0.00097). CONCLUSIONS: Daily abdominal pain and nausea, in combination with a history of ulcer disease, are strong predictors of major gastric or duodenal disease. Patients with reflux without these predictors are highly unlikely to have a major disease involving the stomach or duodenum, and are suitable candidates for esophagoscopy alone.

Accuracy of EUS criteria and primary tumor site for identification of mediastinal lymph node metastasis from non-small-cell lung cancer.

BACKGROUND: EUS with FNA is useful for staging non-small-cell lung cancer. However, benign mediastinal adenopathy is common. The aims of this study were to identify clinical factors, especially primary tumor location, and EUS lymph nodal characteristics predictive of aortopulmonary window and subcarinal lymph node metastases of non-small-cell lung cancer. METHODS: Patients with known or suspected non-small-cell lung cancer underwent EUS staging at which EUS-FNA was performed for all identified mediastinal lymph nodes. Clinical characteristics, primary tumor data, EUS findings, and histopathology were reviewed. Exact tests were performed for both aortopulmonary window and subcarinal lymph nodes to identify factors predictive of malignant cytology. RESULTS: Ninety-two patients with non-small-cell lung cancer were included. Fifty-one had aortopulmonary window, and 73 had subcarinal lymph nodes on EUS. The EUS with FNA specimens were interpreted as suspicious or diagnostic for malignancy for 9 aortopulmonary window and 9 subcarinal lymph nodes. When comparing benign vs. malignant EUS with FNA findings for aortopulmonary window and subcarinal lymph nodes, only lymph node size of 1 cm or greater and sharp lymph nodal edges were associated with malignancy in lymph nodes at both sites, whereas primary tumor site, lymph node shape, and echogenicity were associated with malignant subcarinal nodes. When 4 classic lymph nodal features of malignancy were evaluated, the presence of 3 or more typical features had positive and negative predictive values of, respectively, 41% and 96%. CONCLUSIONS: Although tumor location and EUS lymph nodal characteristics are associated with malignant involvement of lymph nodes, the accuracy of these predictors does not obviate the need for cytologic evaluation. EUS with FNA should be performed for all lymph nodes when an abnormal finding will alter management.

Tele-endoscopy: a way to provide diagnostic quality for remote populations.

BACKGROUND: Flexible endoscopy plays an important role in digestive health. However, access to endoscopy is limited in many rural areas throughout the world. Training non-physician personal to perform diagnostic endoscopy and to transmit images to a central hospital, where experienced endoscopists can review the procedures, may improve digestive health for patients in remote areas. The aim of this study was to evaluate the diagnostic quality and accuracy of upper-GI tele-endoscopy. METHODS: Fifty patients scheduled for EGD underwent upper-GI tele-endoscopy. The procedures were observed simultaneously by the endoscopist and a gastroenterologist observing from a remote station connected by 4 integrated services digital network telephone lines. The interpretation of the findings by both were compared and concordance for diagnosis of major and minor lesions was analyzed. RESULTS: Tele-endoscopic image quality was adequate to support diagnosis of abnormal lesions by the remote observer. Technical issues included worsening image quality caused by mild pixelation during rapid endoscope movement and rare loss of the telephone lines. The endoscopist identified 47 different major and 44 minor findings in the 50 patients. The observer missed one major lesion (columnar-lined esophagus) because of suspected inflammation and described 10 non-existing major lesions (sensitivity 98%: 95% CI[89%, 99%], specificity 80%: 95% CI[66%, 90%]). Some of the differences were because of interobserver variability. CONCLUSIONS: Upper-GI tele-endoscopy by using telephone lines has good diagnostic quality and is highly sensitive with regard to major findings. The misinterpretation of certain findings (esophageal ring, gastric erosions) may be caused by interobserver variability. The data strongly suggest that endoscopist and observer see similar endoscopic views.

Detection of occult liver metastases during EUS for staging of malignancies.

BACKGROUND: EUS is commonly used in the staging of GI, thoracic, and other malignancies. Studies suggest EUS can detect occult liver metastases, but the frequency with which this occurs is unknown. METHODS: Records were reviewed for all patients seen during a 3-year period who underwent EUS of the upper-GI tract for staging of known or suspected malignancy. Patients were included if there was histopathologic evidence of malignancy, they had undergone noninvasive liver imaging within 6 weeks of EUS, and liver surveillance was specifically mentioned in the report of the EUS procedure. RESULTS: A total of 222 patients were included. Liver lesions were seen in 27 patients, 17 of whom had an abnormal noninvasive liver imaging test. EUS-guided FNA of the liver was performed in 21 patients and was diagnostic of malignancy in 15 (6.8%), 5 of whom (2.3%) had normal noninvasive imaging. In 6 patients, the EUS-guided FNA result was benign. EUS missed liver lesions in 4 patients known to have abnormalities by other imaging modalities. CONCLUSIONS: EUS can detect occult liver metastases in patients in whom noninvasive hepatic imaging studies are normal, although the frequency at which such lesions are detected is low. Liver surveillance during EUS is worthwhile for patients in whom there is another indication for the procedure; but, at present, EUS should not replace traditional imaging modalities.

A prospective, blinded study of diagnostic esophagoscopy with a superthin, stand-alone, battery-powered esophagoscope.

OBJECTIVES: A more widely available, well-tolerated, and cost-effective technique is needed to screen a broad population at risk for esophageal cancer. An ideal solution might be to perform unsedated esophagoscopy with an entirely self-contained, small-caliber endoscope. In a prospective, blinded study in three phases, we compared the feasibility, patient tolerance, and diagnostic accuracy of esophagoscopy performed with a prototype, superthin, battery-powered esophagoscope (BPE) with standard video esophagogastroduodenoscopy (SVE). METHODS: In phase I, 10 healthy volunteers underwent both peroral and transnasal esophagoscopy with BPE to evaluate the technical feasibility of the examination. For phases II and III, patients were recruited to have BPE before SVE. In phase II, both procedures were performed with conscious sedation. In phase III, the BPE was performed with only topical anesthesia. Two endoscopists assessed the technical performance of the endoscope and patient tolerance and recorded the esophageal findings independently. RESULTS: In phase I, all endoscopists reported adequate visualization of the esophagus in the 10 volunteers. A total of 181 patients were evaluated in phases II and III (89 in phase II, 92 in phase III). The sensitivity for detecting columnar lined esophagus was 94% in phase II and 95% in phase III. The sensitivity for all esophageal findings was 87% and 86% in phases II and III, respectively. The technical performance of the endoscope was significantly worse for BPE compared with the SVE. The patient tolerance as evaluated by the endoscopist was similar for both procedures. Ninety-five percent of the patients undergoing unsedated BPE were willing to have the procedure repeated under similar circumstances. CONCLUSIONS: Unsedated esophagoscopy with a 3.1-mm, battery-powered, stand-alone esophagoscope is feasible, well tolerated, and accurate in detecting esophageal pathologies. It might be an efficient and cost-effective screening tool for the detection of columnar lined esophagus.

Diagnosis of benign cysts of the mediastinum: the role and risks of EUS and FNA.

BACKGROUND: Benign mediastinal cysts, which account for approximately 20% of mediastinal masses, may be diagnostic challenges. Information regarding the use of EUS and EUS-guided FNA in this setting is limited. The aim of this study was to demonstrate the value and potential risks of EUS and EUS-FNA in the diagnosis of mediastinal foregut cysts. METHODS: The EUS database of a single tertiary referral center was reviewed for the diagnosis of benign mediastinal cysts. Twenty patients were identified who underwent 23 EUS examinations for suspected mediastinal cysts (n = 4), for follow-up of a known cyst (n = 3), or for a mediastinal mass of unknown origin (n = 16). RESULTS: In 19 patients, the definite diagnosis of a mediastinal cyst was established by EUS. Twelve cysts appeared anechoic, 6 were hypoechoic, and one anechoic cyst contained small echoic foci. CT (n = 17) or magnetic resonance imaging (n = 1) was performed in 18 cases; only 4 of these were diagnostic of a cyst. In 3 cases, the cyst contents were aspirated by EUS-FNA. In a fourth case, a solid-appearing duplication cyst, misdiagnosed by EUS, was sampled with FNA and core biopsy. This patient developed severe sepsis secondary to mediastinitis 4 days later. Thoracotomy revealed an infected bronchogenic cyst. CONCLUSIONS: EUS provides a minimally invasive approach to the diagnosis of benign mediastinal cysts and may be more accurate than CT or other imaging modalities. Aspiration of suspected cysts should be undertaken with caution, given the risk of infection.

Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope.

BACKGROUND: A cost-effective technique is needed for screening of a broad population at risk for esophageal cancer. A solution would be to have non-physician endoscopists perform esophagoscopy with small-caliber battery-powered endoscopes. METHODS: In a prospective blinded study, the diagnostic accuracy of sedated esophagoscopy performed by a trained nurse practitioner with a battery-powered 4-mm diameter endoscope was compared with that for a sedated standard video-endoscopy performed by a gastroenterologist. Patients were recruited to undergo peroral esophagoscopy by the nurse practitioner followed by sedated standard endoscopy by the supervising gastroenterologist, each blinded to the findings of the other. Major esophageal findings of nurse practitioner and gastroenterologist were compared. RESULTS: Findings in 40 patients were analyzed. In 4 patients both endoscopists could not assess the presence or absence of columnar-lined esophagus because of severe erosive esophagitis (n = 3) or severe candida-esophagitis (n = 1). By using sedated standard endoscopy as the standard, on a per finding basis, esophagoscopy by the nurse practitioner had a sensitivity for columnar-lined esophagus of 89%: 95% CI [75%, 97%] and specificity of 96%: 95% CI [84%, 99%]. The missed columnar epithelium was a 3 x 3-mm island. For all lesions, the sensitivity of endoscopy performed by the nurse practitioner with the battery-powered endoscope was 75%: 95% CI [67%, 82%] and specificity 98%: 95% CI [96%, 99%]. The nurse practitioner missed all of 4 rings (3 considered clinically irrelevant). CONCLUSION: Esophagoscopy with a battery-powered 4-mm diameter endoscope by a non-physician endoscopist is feasible and accurate in detecting esophageal pathologies. It may be an efficient screening method for the detection of columnar-lined esophagus. There was a distinct underestimate of the presence of esophageal rings.