Search PubMed⌕ Search

Biomedical subjects

M L Kochman

Publications and source records attributed to M L Kochman.

At least 37 records · Page 2Linked to original sources
PubMed2000

EUS in preoperative staging of pancreatic cancer.

BACKGROUND: Endoscopic ultrasound (EUS) is believed to be highly accurate in the local (T) and nodal (N) staging of pancreatic cancer. However, there are scant data concerning the predictive value of EUS for resectability of pancreatic adenocarcinoma. This study was performed to determine the accuracy of TNM staging by EUS in patients with pancreatic adenocarcinoma and to evaluate the role of preoperative TNM staging by EUS for determining resectability in patients with pancreatic adenocarcinoma. METHODS: This is a retrospective review of a cohort of 89 patients evaluated preoperatively with EUS for pancreatic adenocarcinoma between January 1995 and December 1997. Preoperative TNM classification by EUS was compared with surgical and histopathologic TNM staging. Resectability rates were determined and compared with the preoperative TNM staging by EUS. RESULTS: The overall accuracy of EUS for T and N staging was found to be 69% and 54%, respectively. The overall proportion of tumors that were deemed resectable by EUS and were actually found to be resectable during surgical exploration was 46%. The proportion of tumors staged as T4 N1, T4 N0, T3 N1 and T3 N0 by EUS that were found to be resectable during surgical exploration was 45%, 37%, 44% and 62%, respectively. CONCLUSIONS: In a tertiary referral patient population, EUS is not as accurate as previously reported in the T and N staging of pancreatic cancer. EUS is also not predictive of resectability in stage T3 or T4 pancreatic cancer.

Adenocarcinoma↗
PubMed2000

Endoscopic management of biliary disease.

Endoscopic management of biliary disease remains at the forefront of minimally invasive means of providing therapy, as well as contributing important diagnostic information in complex clinical scenarios. The authors review recent advances and reported trials of therapy and revisit important controversial issues. The management and diagnosis of choledocholithiasis are discussed, as well as endoscopic techniques for attaining biliary access at endoscopic retrograde cholangiopancreatography. In addition, management of biliary anastomotic strictures in liver transplant patients, role of cholangioscopy, and recent advances in stent technology are reviewed.

Journal Article↗
PubMed2000

Role of endoscopic ultrasound and magnetic resonance imaging in the preoperative staging of pancreatic adenocarcinoma.

OBJECTIVE: Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) have both been assessed individually as staging modalities for pancreatic cancer. The aim of our study was to assess whether tumor staging by both EUS and MRI in the same cohort of patients could predict resectability and unresectability in patients with pancreatic cancer. METHODS: A review of 63 patients evaluated preoperatively with both EUS and MRI for pancreatic adenocarcinoma between January 1995 and December 1998 was done. Patients were staged as resectable or unresectable by predefined criteria. Preoperative staging by both modalities was compared to surgical outcome and the sensitivity and predictive values of each modality for determining resectability and unresectability was determined. RESULTS: EUS did not allow for complete T- and N-staging in 10 patients; therefore, for EUS, the final analysis was done on 63 of 73 patients (86%). EUS correctly staged 22 of 36 patients with resectable tumors. The sensitivity of EUS for resectability was 61%, with a positive predictive value of 69%. All 73 patients had complete MRI examinations; therefore, the final analysis was done on all 73 patients. MRI correctly staged 30 of 41 patients with resectable tumors. The sensitivity of MRI for predicting resectability was 73% with a positive predictive value of 77%. MRI and EUS both predicted resectability in 18 patients, of whom 16 (89%) were found to be resectable on surgical exploration. MRI and EUS both predicted unresectability in 17 (27%) patients, of whom 4 (24%) were found to be resectable on surgical exploration. When both MRI and EUS agreed on resectability, the positive predictive value for resectability was 89%. When both MRI and EUS agreed on unresectability, the positive predictive value for unresectability was 76%. CONCLUSIONS: Neither MRI nor EUS alone were highly sensitive or predictive of resectability. However, when both tests agreed on resectability, nearly all patients were found to be resectable on surgical exploration.

Adenocarcinoma↗
PubMed2000

Esophageal dilation for endosonographic evaluation of malignant esophageal strictures is safe and effective.

OBJECTIVE: Endoscopic ultrasound (EUS) is accepted as the most accurate modality for T- and N-staging of esophageal cancer, but some malignant strictures prevent passage of the echoendoscope beyond the level of the tumor. This incomplete evaluation may decrease staging accuracy. Previous studies have yielded conflicting results regarding the safety and efficacy of esophageal dilation for EUS. METHODS: We prospectively evaluated 267 consecutive patients undergoing EUS for esophageal carcinoma staging at our institution over a 66-month period to determine the number of patients requiring dilation for EUS examination, the success of dilation, safety of dilation, and clinical importance. RESULTS: Among 267 endosonographic examinations of the esophagus, 81 (30.3%) required dilation to advance the echoendoscope beyond the level of the stricture. After dilation was performed, the echoendoscope could be passed through the stricture in 69 patients (85.2%), and in 63 of 67 of the patients dilated to > or = 14 mm (94.0%). No complications have occurred secondary to the dilations performed to permit completion of the endosonographic examination. Tumor staging by EUS after dilation was T2 (14.8%), T3 (56.8%), and T4 (21.0%), nodal staging N0 (14.6%) and N1 (75.3%); and M1 (9.9%). CONCLUSIONS: We conclude that incremental, stepwise dilation of malignant strictures to 14 mm is safe and effective in permitting echoendoscope passage beyond the stenosis. The presence of a malignant stricture does not seem to diminish the utility of EUS staging of esophageal cancer.

Catheterization↗
PubMed1999

EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms.

BACKGROUND: Computerized tomography (CT), magnetic resonance imaging (MRI), and transabdominal ultrasound frequently fail to detect ampullary lesions. Endoscopic ultrasound (EUS) is a sensitive modality for detecting and staging ampullary tumors. Accurate staging may be affected by biliary stenting, which is frequently performed in these patients with obstructive jaundice. The present study assessed the accuracy of ampullary tumor staging with multiple imaging modalities in patients with and those without endobiliary stents. METHODS: Fifty consecutive patients with ampullary neoplasms from two endosonography centers were preoperatively staged by EUS plus CT (37 patients), MRI (13 patients), or angiography (10 patients) over a 3(1/2) year period. Twenty-five of the 50 patients had a transpapillary endobiliary stent present at the time of endosonographic examination. Accuracy of EUS, CT, MRI, and angiography was assessed with the TNM classification system and compared with surgical-pathologic staging. The influence of an endobiliary stent present at the time of EUS on staging accuracy of EUS was also evaluated. RESULTS: EUS was more accurate than CT and MRI in the overall assessment of the T stage of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%). No significant difference in N stage accuracy was noted between the three imaging modalities (EUS 68%, CT 59%, MRI 77%). EUS T stage accuracy was reduced from 84% to 72% in the presence of a transpapillary endobiliary stent. This was most prominent in the understaging of T2/T3 carcinomas. CONCLUSIONS: EUS is superior to CT and MRI in assessing T stage but not N stage of ampullary lesions. The presence of an endobiliary stent at EUS may result in underestimating the need for a Whipple resection because of tumor understaging.

Adult↗
PubMed1999

Primary care physicians' decisions to perform flexible sigmoidoscopy.

OBJECTIVE: This study was designed to identify factors that influence primary care physicians' willingness to perform flexible sigmoidoscopy. MEASUREMENTS: Using a mailed questionnaire, we surveyed all 161 primary care physicians participating in a large health care system. We obtained information on training, current practice patterns, beliefs about screening for colorectal cancer, and the influence of various factors on their decision whether or not to perform flexible sigmoidoscopy in practice. MAIN RESULTS: Of the 131 physicians included in the analysis, 68 (52%) reported training in flexible sigmoidoscopy, of whom 36 (53%) were currently performing flexible sigmoidoscopy in practice. Time required to perform flexible sigmoidoscopy, availability of adequately trained staff, and availability of flexible sigmoidoscopy services provided by other clinicians were identified most often as reasons not to perform the procedure in practice. Male physicians were more likely than female physicians to report either performing flexible sigmoidoscopy or desiring to train to perform flexible sigmoidoscopy (odds ratio 2.61; 95% confidence interval 1.10, 6.23). This observed difference appears to be mediated through different weighting of decision criteria by male and female physicians. CONCLUSIONS: Approximately half of these primary care physicians trained in flexible sigmoidoscopy chose not to perform this procedure in practice. Self-perceived inefficiency in performing office-based flexible sigmoidoscopy deterred many of these physicians from providing this service for their patients.

Adult↗
PubMed1999

Endoscopic management of biliary tract disease.

Endoscopic management of biliary tract disease continues to be influenced by new advances in technology and shaped by further examination of old controversies. This review covers and highlights recent world literature concerning biliary endoscopy and its effect on the management of biliary disorders. In particular, we examine the role and consequence of the endoscopic management of choledocholithiasis and the continuing controversy over endoscopic treatment of pancreatic disease. The increasing impact of endoscopic ultrasound in the biliary tree is explored, as well as the latest developments in biliary stent technology.

Journal Article↗
PubMed1999

Use of a push enteroscope improves ability to perform total colonoscopy in previously unsuccessful attempts at colonoscopy in adult patients.

OBJECTIVE: Total colonoscopy with use of a standard adult colonoscope can be difficult in the presence of a redundant or angulated colon. It is often possible to traverse these areas with the use of a thinner, more flexible endoscope. The objective of this study was to evaluate the efficacy of completing total colonoscopy using a push enteroscope when a standard colonoscope was unsuccessful. METHODS: A prospective analysis was performed for 721 consecutive colonoscopies attempted by two gastroenterologists. Those patients in whom complete colonoscopy was unsuccessful using the standard colonoscope (Olympus CF-100L) had attempts to complete colonoscopy using the enteroscope (Olympus SIF-100). The extent of each exam was recorded. Additional pathologic findings discovered by the use of the enteroscope and therapeutic interventions performed were additionally noted. RESULTS: Colonoscopy using an enteroscope was performed in 32 patients with successful total colonoscopy in 22 patients (68.7%). Additional pathology was noted in nine patients who had successful complete colonoscopy using the enteroscope; adenomatous polyp (n = 5), adenocarcinoma (n = 1), bleeding source (n = 2), and extent of colitis (n = 1). Total colonoscopy rate using standard adult colonoscope was 93.2% (630 of 676) when cases with poor bowel preparation (n = 23) and obstructing lesions (n = 14) were excluded. When the results of successful colonoscopies with the enteroscope were included, the overall completion rate of total colonoscopy improved to 96.4% (652 of 676). CONCLUSION: The use of the enteroscope to help evaluate patients who have had incomplete colonoscopies with the standard colonoscope increases the diagnostic yield of colonic examination.

Adult↗
PubMed1999

Melanoma in the gastrointestinal tract.

OBJECTIVE: This article focuses on the clinical, diagnostic, and therapeutic aspects of malignant melanoma metastases to the gastrointestinal (GI) tract. The subject of primary malignant melanoma arising from the GI tract is also discussed. Malignant melanoma is the most common tumor metastatic to the GI tract, and can present with fairly non-specific symptoms. METHODS: Up to 60% of patients with melanoma are found to have metastases at autopsy. Frequent GI sites of invasion include the small bowel (50%), colon (31.3%), and anorectum (25%), seen in our institution over the past 9 yr. Malignant melanoma is a frequent source of metastases to the gastrointestinal (GI) tract. RESULTS: Herein we report the case of a melanoma masquerading as a rectal polyp. We have also discovered 16 cases of melanoma metastases to the GI tract, at our institution, over the past 9 yr. The most frequent sites included small bowel (50%), colon (31.3%), and anorectum (25%). CONCLUSION: Despite innocuous gastrointestinal symptoms, metastatic melanoma should be a diagnostic consideration in any patient with a history of melanoma.

Adult↗
PubMed1998

Endoscopic ultrasound-guided real-time fine-needle aspiration: clinicopathologic features of 60 patients.

Diagnosis of lesions of the gastrointestinal tract and adjacent structures is possible using an imaging modality, endoscopic ultrasonography (EUS). Fine-needle aspiration (FNA) is a suitable and cost-effective technique for obtaining cytohistologic material to confirm the diagnosis. EUS is capable of both characterizing the lesion and then guiding the FNA under real-time (RT) ultrasound guidance using a through-the-scope needle aspiration system. The goal of this study was to determine the diagnostic accuracy of this technique and to describe the clinicopathologic features. Sixty patients underwent EUS-guided RTFNA of 64 lesions, including pancreas (n = 45), periluminal lymph nodes (n = 12), mediastinal and retroperitoneal masses (n = 4), and hepatobiliary masses (n = 3). Follow-up data were obtained by surgery, histopathology, or clinical course. Thirty-one lesions were malignant, eight were atypical/suspicious, 16 were non-neoplastic, and nine were non-diagnostic. Of the 55 lesions with sufficient material for interpretation, 54 had follow-up confirmation of the RTFNA diagnosis. The calculated sensitivity and specificity for malignancy was 90% and 100%, respectively. Diagnostic accuracy for malignancy was excellent for gastrointestinal associated lymph nodes (100%), mediastinal and retroperitoneal masses (100%), somewhat less so for pancreatic tumors (94%), and poor for hepatobiliary lesions (33%). EUS-guided RTFNA is accurate for sampling small gastrointestinal tract-associated lesions. EUS-guided RTFNA should be considered as a procedure of choice in selected patients when the results will influence management decisions.

Abdominal Neoplasms↗
PubMed1998

Splenic vein thrombosis secondary to focal pancreatitis diagnosed by endoscopic ultrasonography.

We report splenic vein thrombosis diagnosed by endoscopic ultrasonography (EUS) after the failure of extracorporeal ultrasound and contrast enhanced computed tomography to establish the diagnosis in a patient with gastrointestinal bleeding and anemia. Subsequent preoperative magnetic resonance imaging revealed findings of retroperitoneal fibrosis and confirmed the EUS findings. Splenic vein thrombosis is a well-known cause of gastrointestinal bleeding and splenomegaly; pancreatitis and pancreatic tumors are its most common underlying causes. Abdominal ultrasound and computed tomography are frequently used to diagnose splenic vein thrombosis. We discuss the use of EUS for diagnosis of vascular anomalies in the gastrointestinal tract and the association of splenic vein thrombosis, retroperitoneal fibrosis, and pancreatitis.

Endosonography↗
PubMed1997

Endosonographic differentiation of benign and malignant stromal cell tumors.

BACKGROUND: Endosonography (EUS) is a valuable technique for diagnosing gastrointestinal stromal cell tumors. However, EUS features that are predictive of malignancy in these tumors have not been defined. METHODS: Videotapes and photographs of EUS examinations performed prior to surgical resection of 35 stromal cell tumors (9 malignant) were blindly reviewed by a single examiner. EUS features associated with malignancy were determined. Interobserver agreement in interpreting these features was then measured among a panel of five expert endosonographers who judged EUS videotapes of 35 resected stromal cell tumors (10 malignant). RESULTS: Stepwise logistic regression analysis demonstrated that tumor size (diameter > 4 cm), irregular extraluminal border, echogenic foci, and cystic spaces were independently associated with malignancy in stromal cell tumors (p < 0.05). Interobserver agreement for irregular extraluminal border, echogenic foci, and cystic spaces, as measured by mean kappa statistic, was 0.43, 0.39, and 0.28, respectively. For the five experts, the sensitivity for detecting malignancy ranged between 80% to 100% when at least two of the three features were judged to be present. The likelihood of finding malignancy ranged between 0% to 11% for the experts when all three features were judged absent. CONCLUSIONS: Tumor size and certain EUS features are useful for predicting malignancy in stromal cell tumors. Absence of these features indicates benign disease. Agreement among experts in interpreting these EUS features is fair to moderate.

Diagnosis, Differential↗
PubMed1997

Device choice and experience level in endoscopic foreign object retrieval: an in vivo study.

BACKGROUND: Successful foreign object retrieval may depend on device choice and the experience level of the endoscopist, although these factors have not been systematically evaluated. METHODS: In anesthetized pigs, the ability to retrieve foreign objects (metal tack, button disc battery, wooden toothpick) placed endoscopically into the stomach was assessed. Seven university medical center gastroenterology attending physicians (5 clinical and 2 basic science research [BSR]), and 4 fellows-in-training participated. The devices used were the Roth retrieval net, rat tooth forceps, Dormia basket, polypectomy snare, and radial jaw forceps. The time to retrieve each object into an esophageal overtube within a 5 minute maximum was measured. RESULTS: Only the Roth net and Dormia basket were successful in retrieving the button disc battery, although the Roth net was superior (100% vs 27%, Fisher p < 0.025). All devices were equally successful at retrieving the tack (82% to 100%, p = NS). The snare was significantly faster than the Roth net (p < 0.05). For the tack, there was significantly fewer difficulties encountered with the snare than the Roth net (Fisher p < 0.03). The Roth net was incapable of retrieving the toothpick; the other devices were equally successful (91% to 100%). The clinical attendings had a significantly higher success rate (95%) than the fellows (82%, chi squared p < 0.05) or combined fellows/BSR attendings (80%, p < 0.02), and were significantly faster than the fellows (p < 0.0002) or the fellows/BSR attendings (p < 0.0003). CONCLUSIONS: The Roth net is the best device for retrieving smooth objects such as the button disc battery. For sharp objects, such as the tack and toothpick, best results were achieved with the snare, although the forceps were also effective. More experienced endoscopists had higher success rates and faster retrieval times. Both device choice and the experience level of the endoscopists have an impact on successful foreign object retrieval.

Animals↗