Pre-operative staging of recto-sigmoid colon carcinoma by upper gastrointestinal endoscopic ultrasonography.

BACKGROUND/AIMS: To assess the accuracy of a new generation endoscopic ultrasonography (EUS)(GF-M200) in pre-operative staging of recto-sigmoid colon carcinoma invasion and lymph node metastasis. METHODOLOGY: Seventy-three patients with biopsy proven colon cancer were included in this study. These comprised 60 patients with rectal carcinoma and 13 patients with sigmoid carcinoma. All patients were pre-operatively examined by EUS. Pathological findings of the depth of tumor invasion and presence of lymph node metastasis were correlated with EUS. RESULTS: EUS has an overall accuracy rate of 89% in staging of recto-sigmoid cancer. The diagnostic accuracy rate was 83% for T1, 83% for T2, 93% for T3, and 71% for T4. Understaging and overstaging occurred in 6% and 6%, respectively. In determining lymph node metastasis, the overall accuracy rate was 77%, with a sensitivity and specificity rate of 77% and 76%, respectively. CONCLUSIONS: EUS is a valuable staging modality in the staging of the depth of tumor invasion, not only for rectal carcinoma but also for tumors located at the sigmoid colon.

Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy.

BACKGROUND/AIMS: This study is conducted to evaluate the feasibility of percutaneous transhepatic gallbladder drainage prior to laparoscopic cholecystectomy for the treatment of gallbladder empyema. We also determine the sonographic findings, causative organism, clinical signs and symptoms, laboratory data, associated underlying medical disorders and the complications related to both cholecystostomy and laparoscopic cholecystectomy. METHODOLOGY: One hundred and forty-five cases of gallbladder empyema were included in this study which was composed of 80 males and 65 females, aged 22-94 years with a mean age of 71-years. All patients underwent percutaneous transhepatic gallbladder drainage under ultrasound and fluoroscopic guidance, and laparoscopic cholecystectomy was carried out thereafter. We analyzed the clinical presentations (signs, symptoms, laboratory and ultrasonographic findings, concomitant medical disorders), causative organisms and the complications related to percutaneous cholecystostomy and laparoscopic cholecystectomy. RESULTS: Percutaneous transhepatic gallbladder drainage was performed successfully in all patients within 48 hours after clinical diagnosis of acute cholecystitis. Complications related to percutaneous transhepatic gallbladder drainage were bile leakage after tract dilatation noted in 2 patients (1.4%), and 20 (14%) patients had pain at the puncture site which radiated to the right shoulder during the procedure, but resolved spontaneously within an hour later. On admission, 102 (70%) patients presented as right upper quadrant pain, 39 (27%) as epigastric pain, 90 (62%) as fever, 108 (74%) patients had leukocytosis, and 33 (22.7%) patients were septic. AST and ALT were elevated in 57% and 51% of patients, respectively. Alkaline phosphatase was elevated in 56% of patients, and 34% of those patients had combined common bile duct stones. Gallbladder stones were documented in 135 (93%) patients, while the remaining 10 (7%) cases were acalculous. Five (3.4%) patients had combined gallbladder adenocarcinoma, 7 (4.8%) had liver abscess, while 13 (9%) had biliary pancreatitis. The ultrasonographic findings included gallbladder distension (93%), wall thickening (90%), pericholecystic fluid accumulation (15%), intraluminal sludge or stone (93%) and intraluminal air (13.9%). Bile culture were positive in 83% of the cases and showed gram-negative bacteria in 75%, gram-positive in 30%, anaerobes in 7%, while no growth in the remaining 17% of the cases. The common pathogens were Escherichia coli (57%), Enterococcus (27%), Klebsiella pneumonia (18%), Morganella morganii (7.6%), Pseudomonas aeruginosa (4.1%) and Salmonella (0.7%). The total postoperative complication rate was 17%, which included wound infection, bleeding, subhepatic abscess, cystic duct stump leak, common bile duct injury and pneumonia. Postoperative mortality was 2.6%. Conversion rate to open cholecystectomy was 27%. Clinical conditions improved within 48 hours after cholecystostomy in 93% of patients. Time interval between cholecystostomy and elective cholecystectomy was 2-21 days with a mean of 4 days. Total hospital stay was 5-38 days (mean: 11 days). CONCLUSIONS: Percutaneous transhepatic gallbladder drainage is a safe and effective procedure for the initial management of gallbladder empyema. We highly recommend this preoperative drainage procedure in patient with sepsis, and for those high-risk patients such as old age and with underlying medical illnesses. This procedure can stabilized the patient so that an appropriate therapeutic planning can be achieved.

Rectal leiomyosarcoma diagnosed by endoscopic ultrasonography.

A 67 year-old man was admitted to the Tainan Municipal Hospital due to a protruding mass, usually noted during defecation. Digital examination revealed a single, smooth, large mass over the rectum, occupying almost the entire lumen. Colonoscopy, barium enema, and computed tomography (CT) demonstrated a submucosal tumor of the rectum. Endoscopic ultrasound (EUS) study showed that the tumor originated from the muscle layer. Based on the size, margin and echogenicity of the mass, a malignant neoplasm, probably leiomyosarcoma, was diagnosed. Post-operative histologic examination confirmed that the resected tumor was leiomyosarcoma. Existing ancillary procedures like colonoscopy, abdominal CT, magnetic resonance image (MRI), and barium enema are neither reliable nor accurate in locating which layer the lesion originates. Colonoscopic biopsy is disappointing since submucosal tumor is usually inaccessible. EUS study can provide us with a more distinct image with regards to tumor origin, size, margin and echogenicity. This report emphasizes the important role of EUS in the pre-operative diagnosis of submucosal tumors of the rectum. Furthermore, this tool can aid the surgeons whether wide excision or an abdomino-perineal resection should be performed.

Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis.

BACKGROUND: Intraductal ultrasound (IDUS) as an adjunct to ERCP for detection of extrahepatic bile duct stones is technically easy, accurate, and safe. This prospective study evaluated IDUS with an "over-the-wire" catheter US probe as an adjunct to ERCP. METHODS: Sixty-five patients, highly suspected to have choledocholithiasis, underwent IDUS during ERCP. The IDUS probe was inserted by means of the duodenoscope into the bile duct without performing a sphincterotomy. All stones identified by IDUS or retrograde cholangiography were removed with either a basket or retrieval balloon after endoscopic sphincterotomy. RESULTS: The final diagnosis was choledocholithiasis in 59 patients. Bile duct diameter ranged from 0.6 to 2.3 cm and stone size from 2 mm to 2 cm. IDUS successfully identified all stones in these patients. IDUS resulted in 2 false-positive diagnoses in the remaining 6 patients without stones (overall accuracy 97%, sensitivity 100%, specificity 67%). Cholangiography detected stones in 55 of the patients with stones (accuracy 94%, sensitivity 93%, specificity 100%). CONCLUSION: IDUS, a safe, technically easy procedure, is highly accurate in the detection of extrahepatic bile duct stones regardless of the diameter of the bile ducts. The "over-the-wire" technique preserves access to the cannulated duct. IDUS is an excellent adjunct to ERCP for the diagnosis of choledocholithiasis. IDUS differentiates stones from air bubbles and prevents unnecessary sphincterotomy.

Preoperative staging of colorectal cancer with a balloon-sheathed miniprobe.

BACKGROUND AND STUDY AIMS: Conventional endoscopic ultrasonography (EUS) is a valuable modality for staging the depth of invasion of colorectal cancer. However, there are difficulties with this technique in reaching as far as the cecal area, traversing tight strictures, and obtaining clear images of smaller lesions. Due to these factors, mis-staging often occurs. The literature shows that the miniprobe is superior to EUS, because of its easy manipulation and better diagnostic accuracy. We therefore conducted a prospective study using a balloon-sheathed miniprobe for colorectal cancer staging. PATIENTS AND METHODS: Eighty-six patients underwent preoperative staging using a miniprobe combined with an outer balloon sheath. Six patients were excluded from lymph-node examination due to local tumor resection. Acoustic coupling was achieved with or without water immersion. The results were compared with the histopathological findings in the resected specimens. RESULTS: The balloon-sheathed miniprobe had an overall accuracy rate of 85 % for T staging, with 100 % in T1; 78 % in T2; 90 % in T3; and 40 % in T4. Lymph-node metastasis was correctly diagnosed in 73 % of cases, with sensitivity and specificity rates of 74 % and 71 %, respectively. It was not possible to obtain clear cross-sectional images using the miniprobe in three patients. CONCLUSIONS: The balloon-sheathed miniprobe is a good alternative for evaluating colorectal tumor lesions, since it can usually obtain cross-sectional images even in markedly stenosed lesions, and the examination can be performed easily with endoscopy, with or without water-infusion techniques. One major limitation with the probe is the difficulty in evaluating deeper structures, such as lymph-node groups and contiguous organ involvement.