Endoscopic ultrasound, endoscopic sonoelastography, and strain ratio evaluation of lymph nodes with histology as gold standard.

BACKGROUND AND STUDY AIMS: Accurate lymph node staging is essential for the selection of an optimal treatment in patients with upper gastrointestinal cancer. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are considered to be the most accurate method for locoregional staging. Endoscopic sonoelastography (ESE) assesses the elasticity of lymph nodes and has been used to differentiate lymph nodes with promising results. The aim of this study was to evaluate the use of EUS, EUS - FNA, ESE, and ESE-strain ratio using histology as the gold standard. PATIENTS AND METHODS: Patients with upper gastrointestinal cancer who were referred for EUS examination were enrolled if surgical treatment was planned and the patient had a lymph node that was accessible for EUS - FNA and EUS-guided fine-needle marking (FNM). The lymph node was classified using EUS, ESE, and ESE-strain ratio. Finally, EUS - FNA and EUS - FNM were performed. The marked lymph node was isolated during surgery for histological examination. RESULTS: The marked lymph node was isolated for separate histological examination in 56 patients, of whom 22 (39 %) had malignant lymph nodes and 34 (61 %) had benign lymph nodes. There were no complications of EUS - FNM. The sensitivity of EUS for differentiation between malignant and benign lymph nodes was 86 % compared with 55 % - 59 % for the different ESE modalities. The specificity of EUS was 71 % compared with 82 % - 85 % using ESE modalities. CONCLUSION: The use of the EUS - FNM technique enabled the identification of a specific lymph node and thereby the use of histology as gold standard. ESE and ESE-strain ratio were no better than standard EUS in differentiating between malignant and benign lymph nodes in patients with resectable upper gastrointestinal cancer.

Endoscopic ultrasound-guided fine-needle marking of lymph nodes.

BACKGROUND AND STUDY AIMS: No previous studies have evaluated the ability of endoscopic ultrasonography to describe the anatomic location of lymph nodes on the basis of a node-to-node comparison. The aim of this study was to assess the feasibility and safety of a new endoscopic ultrasound (EUS)-guided fine-needle technique for marking lymph nodes. PATIENTS AND METHODS: Twenty-five patients with suspected or confirmed malignancies of the upper gastrointestinal tract were prospectively included. EUS-guided fine-needle marking (EUS-FNM) was performed with a silver pin with a diameter that allowed it to fit into a 19-gauge needle. The position of the pin was verified by EUS. End points were the ability to identify and isolate the marked lymph node during surgery and a comparison between the location of the pin as suggested by EUS and the actual location found in the resected specimen. RESULTS: Twenty-three lymph nodes were marked. Nineteen intended surgical isolations were performed. The lymph nodes were isolated in the resection specimens in 18 patients (95 %). In 2 out of 20 cases the pin was not localized by laparoscopic ultrasonography. In 89 % of the cases the marked lymph node was in the same location as described by EUS. One pin (5 %) was not retrieved. In three cases, a small hematoma was observed. There was no sign of long-term complications. CONCLUSION: EUS-FNM with a silver pin in lymph nodes is feasible and safe. EUS-FNM seems to be a suitable tool for evaluating lymph nodes on the basis of a node-to-node comparison.

A new method for three-dimensional laparoscopic ultrasound model reconstruction.

BACKGROUND: Laparoscopic ultrasound is an important modality in the staging of gastrointestinal tumors. Correct staging depends on good spatial understanding of the regional tumor infiltration. Three-dimensional (3D) models may facilitate the evaluation of tumor infiltration. The aim of the study was to perform a volumetric test and a clinical feasibility test of a new 3D method using standard laparoscopic ultrasound equipment. METHODS: Three-dimensional models were reconstructed from a series of two-dimensional ultrasound images using either electromagnetic tracking or a new 3D method. The volumetric accuracy of the new method was tested ex vivo, and the clinical feasibility was tested on a small series of patients. RESULTS: Both electromagnetic tracked reconstructions and the new 3D method gave good volumetric information with no significant difference. Clinical use of the new 3D method showed accurate models comparable to findings at surgery and pathology. CONCLUSIONS: The use of the new 3D method is technically feasible, and its volumetrically, accurate compared to 3D with electromagnetic tracking.

An intraluminal prosthesis may improve healing of a one-layer colonic anastomosis: an experimental study in pigs.

OBJECTIVE: To compare healing of one-layer colonic anastomoses with or without a soluble intraluminal prosthesis (* SBS-tube). DESIGN: Randomised, partly blinded controlled study. SETTING: University hospital, Denmark. SUBJECTS: 16 female Danish country strain pigs, of which 8 had the SBS tube inserted and 8 acted as controls. INTERVENTIONS: One-layer colonic anastomoses either hand-sewn (n = 8, controls) or hand-sewn onto an SBS tube (n = 8). MAIN OUTCOME MEASURES: Macroscopic evaluation, leakage test, breaking strength, histology, oxygen tension in and near the anastomosis peroperatively and 4 days postoperatively. RESULTS: Three quarters of the tubes (n = 8) dissolved in less than 2 hours. Histological examination showed significantly better structured layers and more mucosal epithelial covering in the SBS group. The other histological variables examined were: tissue gap (p < 0.08), inflammation (p < 0.10), breaking strength (p < 0.46) and amount of granulation tissue (p < 0.71), but the last findings were not significant. Oxygen tension at the anastomotic line was better in the SBS tube group, but not significantly so. CONCLUSIONS: We conclude that the SBS tube facilitates the sewing of the anastomosis and may improve healing, possibly because of better apposition of the cut ends and reduced tension in the sutures.

[Curative treatment of ventricular cancer]. / Kurativ behandling af cancer ventriculi.

Extended lymphadenectomy on connection with the surgical treatment of gastric cancer is gaining access in western centres especially since Japanese centres have shown an ever increasing rate of survival over several decades, coupled with the fact that operative procedures have become more sophisticated. The latest prospective studies in the west seem to confirm the value of lymphadenectomy in some patients. Furthermore, correct staging demands extended lymphadenectomy. For patients with gastric cancer, adjuvant preoperative chemotherapy is probably an asset.

Laparoscopic four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle.

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described.

TNM staging and assessment of resectability of pancreatic cancer by laparoscopic ultrasonography.

BACKGROUND: Laparoscopic ultrasonography (LUS) is an imaging modality that combines laparoscopy and ultrasonography. The purpose of this prospective blinded study was to evaluate the TNM stage and assessment of resectability by LUS in patients with pancreatic cancer. METHODS: Of the 71 consecutive patients admitted to our department, 36 were excluded from the study, mainly due to evident signs of metastatic disease or another condition that would preclude surgery. Thus, a total of 35 patients were enrolled in the study. All patients underwent abdominal CT scan, ultrasonography, endoscopic ultrasonography (EUS), diagnostic laparoscopy, and LUS. Histopathologic examination was considered to be the final evaluation for LUS in all but three patients, where EUS was used as the reference. RESULTS: The accuracy of LUS in T staging was 29/33 (80%); in N staging it was 22/34 (76%); in M staging, it was 23/34 (68%); and in overall TNM staging, it was 23/34 (68%). In assessment of nonresectability, distant metastases, and lymph node metastases, the sensitivity was 0.86, 0.43 and 0.67, respectively, for LUS alone. Combining the information gleaned from laparoscopy and LUS, the accuracy in finding nonresectable tumors was 89%. CONCLUSIONS: Diagnostic laparoscopy with LUS is highly accurate in TNM staging and assessment of resectability of pancreatic cancer and should be considered an important modality in the assessment algorithm.

Laparoscopic ultrasonography--a method for staging of upper gastrointestinal cancer.

Laparoscopic ultrasonography (LUS) is a method that can be useful in the staging of upper gastrointestinal cancer. Dedicated transducers are available, and preliminary studies have proposed indications for the use of LUS staging of hepatic, esophageal, gastric, and pancreatic cancer disease. In the staging and resectability assessment of upper gastrointestinal cancer LUS seems to provide important additional information thus avoiding futile laparotomies in non-resectable patients. This short review summarizes some of the most relevant references concerning the use of LUS in upper gastrointestinal tract cancer.

Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis.

OBJECTIVE: To evaluate the diagnostic accuracy of clinical judgment and diagnostic ultrasonography (US) used routinely and to create a scoring system to aid diagnosis. DESIGN: Prospective, double-blind study. SETTING: University hospital, Denmark. SUBJECTS: 222 Consecutive patients suspected of having acute appendicitis admitted between 0800 and midnight from June 1990 to June 1992. INTERVENTIONS: 148 Patients (67%) underwent appendicectomy and the remaining 74 patients were observed. 193 Patients (87%) had a diagnostic US examination. 21 Predictive variables were collected prospectively to create a scoring system. MAIN OUTCOME MEASURES: Results of surgical pathological findings, clinical outcome (observed group), diagnostic US, and values of diagnostic score. RESULTS: The decision to operate was made by a junior surgeon solely on the clinical examination, which yielded a diagnostic accuracy of 76%, specificity of 58%, and negative appendicectomy rate of 36%. 193 Patients underwent diagnostic US conducted by the radiologist on call of whom 123 were operated on, 78 for histologically proven appendicitis. US had a diagnostic accuracy of 72%, sensitivity of 49%, and specificity of 88%. Of the 21 predictive factors for acute appendicitis 11 were significant (p < 0.05): total white cell count (WCC) (>10 x 10[9]/1), migration of pain to the right lower quadrant, gradual onset of pain, increasing intensity of pain, pain aggravated by movement, pain aggravated by coughing, anorexia, vomiting, indirect tenderness (Rovsing's sign), muscle spasm, and sex. These 11 predictors were assigned an appropriate weight, based on the likelihood ratio, and used to create a scoring system. The score performed poorly if it was used to separate patients for observation and those for appendicectomy. However, if the score was used with two cut-off points resulting in three test zones (low, intermediate, and high risk of having acute appendicitis), some diagnostic benefit was seen for those patients within the zones of high and low probability. CONCLUSION: The clinical judgment of a junior surgeon was disappointing, and diagnostic aids are desirable to reduce the negative appendicectomy rate. Diagnostic US performed poorly as a routine procedure. Application of an up to date scoring system might be of some help to patients with a high or low probability of acute appendicitis, but any conclusion about its clinical application cannot be drawn from this study.

[Pre-therapeutic assessment of resectability in patients with upper gastrointestinal cancer. Combined use of endoscopic ultrasonography and laparoscopy]. / Praeterapeutisk resektabilitetsvurdering af patienter med øvre gastrointestinal cancer. Kombination af endoskopisk ultralydskanning og laparoskopi.

The combined use of endoscopic ultrasonography (EUS) and laparoscopy for the assessment of resectability in patients with upper GI tract cancer was prospectively evaluated in 57 patients. Laparoscopy was able to fill the informational gap in all the patients (n = 6) where EUS failed to give a complete assessment of resectability. This study suggests that the combination of EUS and laparoscopy can reduce the need for "necessary" laparoscopies to about 10%.

The relationship between gut hormone secretion and gastric emptying in different phases of the migrating motor complex.

BACKGROUND: No studies are available on the relationship between the response of gut hormones and gastric emptying in different phases of the migrating motor complex. This study examined whether basal gut hormone concentrations in plasma before food ingestion are predictors of emptying characteristics and whether different hormone secretion patterns are associated with specific alterations in emptying rate. METHODS: Twelve healthy men were examined on two occasions: one with meal ingestion in phase I and the other with meal ingestion in phase II. The meal consisted of an omelette labelled with 99mTc followed by 150 ml water labelled with 111In. Plasma concentrations of gastrin, cholecystokinin, motilin, and peptide YY were measured in the fasting state, immediately after food ingestion, and at 15-min intervals in the postprandial period. RESULTS: New findings from the present study include a higher incremental integrated postprandial motilin response in phase I than in phase II (998 pmol/l*30 min (495 to 2010) versus 210 pmol/l*30 min (-270 to 2323), p < 0.05), and a linear relationship between median total integrated motilin response and solid emptying at 120 min in phase I (Rs = 0.58; p < 0.05). Furthermore, in phase I a linear relationship between total integrated area of cholecystokinin and solid emptying at 120 min was demonstrated (Rs = 0.62; p < 0.05). CONCLUSION: The findings from the present investigation have to be considered in the future design of studies that focus on postprandial release of gastrointestinal hormones. The transition from phase III to phase I is a reproducible and easily recognized pressure event. Therefore, we recommend the use of food ingestion immediately after termination of duodenal phase III.

Vagotomy.

Peptic ulcer disease was for years a common indication for surgery in Danish hospitals and considerable experience in partial gastrectomy was gained. In spite of an unquestionable mortality rate and a number of patients having postgastrectomy complaints, results were generally recognized as acceptable. Danish surgeons were for long reluctant to take up vagotomy and drainage as a primary ulcer operation, but when they did start a large number of procedures were performed. In fact, the use of this treatment culminated during two to three decades. However, on a basis of experiences from these years, Danish research contributed actively to the international evolution of the surgical vagotomy technique, the evaluation of clinical results and the studies of postoperative alterations in gastric physiology. References are selected from an extensive literature and are in no way complete.

Pretherapeutic assessment of resectability in patients with upper gastrointestinal tract cancer by using a combination of endoscopic ultrasonography (EUS) and laparoscopy.

An accurate pretherapeutic assessment of resectability in patients with upper gastrointestinal malignancies (UGIM) is mandatory in order to choose the optimal treatment strategy. Endoscopic ultrasonography (EUS) has significantly reduced the need for exploratory laparotomy in patients with UGIM, but the pretherapeutic evaluation in about 10% of the patients is incomplete due to certain limitations of the EUS. We prospectively evaluated the use and results of diagnostic laparoscopy in patients with UGIM selected for this procedure by EUS. In six patients with incomplete EUS, laparoscopy demonstrated nonresectability in five patients and a resectable tumor in one patient, and laparoscopy thus filled the informational gap in all cases. In addition, laparoscopy confirmed nonresectability in ten patients in whom EUS had suggested nonresectability. By employing the combinated use of EUS and laparoscopy it seems possible to avoid a great number of futile laparoscopies, and it should also reduce the need for explorative laparotomies. Larger prospective studies have been initiated and might be able to confirm this.

[Laparoscopic ultrasonography. A review and authors' own experiences]. / Laparoskopisk ultralydskanning. Oversigt og egne erfaringer.

Laparoscopic ultrasound scanning has long been available, but interest in and reports of the technique have until the last few years been sporadic. The rapid development and growing interest in laparoscopic surgery as well as the advent of commercially available systems designed for laparoscopic ultrasound have resulted in renewed interest in the technique. The available published reports lack prospective, controlled clinical studies with respect to where and when laparoscopic ultrasound would be indicated. A favourable picture is given as concerns the use of laparoscopic ultrasound in the diagnosis and evaluation of primary liver and pancreas tumours as well as liver metastases. Laparoscopic ultrasound is also mentioned as a reliable alternative to cholangiography in laparoscopic cholecystectomy. Our own preliminary experiences with two laparoscopic ultrasound systems and a simple system using an ultrasound finger-probe are described. A laparoscopic ultrasound scanning system consisting of a stiff instrument with a convex (linear) transducer mounted on a flexible support and with the possibility of ultrasound-guided biopsy and colour-Doppler seems optimal. Prospective studies are being carried out to identify areas of utilization and limitations of laparoscopic ultrasound.

[Preoperative laparoscopic evaluation of patients with upper gastrointestinal cancer]. / Laparoskopisk operabilitetsvurdering af patienter med øvre gastrointestinal cancer.

Nineteen consecutive patients with adenocarcinoma of the stomach or pancreas, in whom preoperative ultrasonography and computed tomography were unable to assess the possibility of surgical resection, had a diagnostic laparoscopy performed. In 16 cases the operability could be established from the findings at laparoscopy. All laparoscopies were carried out without major morbidity and with a short postoperative hospital stay. It is concluded that patients belonging to this category should have a diagnostic laparoscopy performed in order to avoid futile laparotomies, which in cases that are unsuitable for surgical treatment are associated with emotional stress, physical morbidity and a prolonged hospital stay.

Preoperative assessment of resectability in gastroesophageal carcinoma by linear array endoscopic ultrasonography.

Preoperative endoscopic ultrasonography (EUS) was performed in 51 consecutive patients with biopsy-verified esophageal or gastric cancer, to judge resectability. A comparison between preoperative EUS and surgical (and histologic) findings was possible in 39 patients (76%). In 33 of these 39 patients (85%) EUS made a correct preoperative assessment. In three cases misinterpretation was due to metastasis outside the viewing field of the echoendoscope. Although based on preliminary experience, we are convinced that EUS will help us to select patients who will ultimately benefit from surgery. Further prospective studies are necessary to clarify the possible benefits in terms of costs, effects of palliation in selected patients, and long-term survival.

[Endoscopic ultrasonography of malignant tumors in the upper abdomen]. / Endoskopisk ultralydskanning af maligne tumorer i øvre abdomen.

Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract is a newly developed, non-invasive investigational method. It combines the direct optical picture of the endoscope with a simultaneous ultrasonographic image of the whole wall of the oesophagus, stomach and duodenum as well as organs and other structures with anatomical relations to the upper gastrointestinal tract. EUS is evaluated for its capacity with respect to cancer of the oesophagus, stomach, pancreas, biliary tree and neuroendocrine tumours, the emphasis being laid on TNM-classification, assessment of resectability and comparison with other imaging techniques. It is concluded that EUS is well-suited for assessing tumour infiltration and thereby also the resectability of these cancer types. Judging whether lymph nodes visualized by EUS are malignant or not is difficult when operating solely from endosonographic and quantitative criteria, and while the sensitivity of EUS for detecting lymph node metastases is in most situations superior to other investigational methods, the specificity and ability to visualize distant metastases is poor. For these purposes the optimal solution appears to be a combination of EUS with CT and/or ultrasound scanning. Future possibility of EUS-guided biopsy will strengthen the method's position in the diagnostic armoury concerning malignant disease in the upper gastrointestinal tract.

Postprandial gallbladder emptying is related to intestinal motility at the time of meal ingestion.

The characteristics of meal-induced gallbladder emptying in healthy individuals are subject to wide variation. We hypothesized that some of the observed variation might relate to ingestion of the meal during different phases of the migrating motor complex (MMC). Recording of gastrointestinal pressure was combined with scintigraphic recording of bile kinetics during infusion of 99mTc-HIDA. The material consisted of 12 healthy men. Group 1 (n = 6) had a fat-rich meal in phase I, and group 2 (n = 6) had the meal in a phase II. With the end of the meal ingestion as zero, the following results emerged. The subjects in group 1 had a median (range) lag period before beginning of gallbladder emptying of 13.5 (9.0-22.5) min. In group 2 gallbladder emptying began during the meal ingestion in four subjects, and the median lag period was 0 min (minimum, -9.0; maximum, 13.5 (p = 0.02)). The median percentage change of gallbladder counts during the observation period of 54 min in group 1 was 11.5% (from 19% filling to 25% emptying). The corresponding figures in group 2 were 41% (from 2% to 91% emptying (p less than 0.05)). This difference was due to the difference in duration of lag periods, as the emptying rates measured from the end of the lag periods were equal. In conclusion, the onset of postprandial gallbladder emptying relates to the phase activity of the MMC at the time of ingestion.