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Michael J Levy

Publications and source records attributed to Michael J Levy.

At least 37 records · Page 2Linked to original sources
PubMed2005

Age-related changes in the pancreas identified by EUS: a prospective evaluation.

BACKGROUND: EUS is an important modality for the diagnosis of pancreatic disease. An understanding of normal pancreatic ductal and parenchymal variation in asymptomatic individuals is essential to improve EUS accuracy. The primary aim of this study was to determine age-related pancreatic parenchymal and ductular changes identifiable on EUS in individuals with no history or symptoms of pancreaticobiliary disease. Secondary aims were to define demographic and clinical factors associated with identifiable pancreatic parenchymal and ductular changes, and to determine the main pancreatic-duct diameter and pancreatic-gland width according to age. METHODS: Patients referred for either upper endoscopy or EUS for an indication unrelated to pancreaticobiliary disease were prospectively enrolled. Patients were stratified by age (<40, 40-60, >60 years). Each patient was assessed for the presence of EUS findings for chronic pancreatitis. Logistic regression was used to identify factors associated with an abnormality. RESULTS: A total of 120 patients (63 men, 57 women; median age, 52 years, interquartile range [IQR] 40-61 years) were prospectively evaluated. At least one parenchymal and/or ductular abnormality was identified in 28% of the patients, with a trend of increasing abnormality with age: <40 years (23%), 40 to 60 years (25%), and >60 years (39%); p = 0.13. No patient had more than 3 abnormal EUS features. Hyperechoic stranding (n = 22) was the most common finding in all age groups. The odds for any abnormality in men (relative to women) was significantly higher (OR 2.9: 95% CI[1.2, 6.8], p = 0.01), with 38% of men and 18% of women having an abnormality. Smoking, low alcohol intake, body mass index, and endoscopic finding were not significantly associated with an abnormal EUS. The overall median pancreatic-gland width and main pancreatic duct diameter were 15 mm (IQR 6-25 mm) and 1.7 mm (IQR 0.9-4.3 mm), respectively. CONCLUSIONS: The frequency of EUS abnormalities in patients without clinical evidence of chronic pancreatitis increases with age, particularly after 60 years of age. The threshold number of EUS criteria for the diagnosis of chronic pancreatitis is variable. However, the typically used standard of 3 or more criteria appears appropriate. A higher number of threshold criteria may be needed in males and to a lesser extent in patients over 40 years of age, which should be related to clinical history and other structural or functional studies. Ductal or parenchymal calculi, ductal narrowing, ductal dilatation, or more than 3 abnormalities appear to be more specific features for the EUS diagnosis of chronic pancreatitis at any age.

Adult↗
PubMed2005

The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum.

BACKGROUND: Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum. METHODS: Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis. RESULTS: Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure. CONCLUSIONS: EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.

Aged↗
PubMed2005

EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice.

BACKGROUND: The diagnosis of autoimmune pancreatitis can be difficult and often requires a larger specimen than can be provided by FNA alone to determine if the tissue sample obtained with EUS trucut biopsy (TCB) is sufficient to allow adequate histologic review to establish the diagnosis of autoimmune pancreatitis. METHODS: EUS TCB was performed in patients presenting with obstructive jaundice who were suspected of having autoimmune pancreatitis based on their clinical, laboratory and imaging studies. The charts were retrospectively reviewed to determine the feasibility of TCB. RESULTS: Between August 2002 and June 2004, 3 patients with obstructive jaundice and suspected autoimmune pancreatitis (AIP) underwent EUS TCB. In each case, a diagnosis of pancreatic cancer also was considered, and surgical resection was the planned therapy before the patient underwent EUS TCB. Histologic review of the TCB specimens established the diagnosis of AIP in two patients and identified nonspecific changes of chronic pancreatitis in the third patient. EUS-guided FNA was performed in two of the 3 patients and failed to establish the diagnosis in either patient. Other than mild transient abdominal pain (n = 1), no complications were identified. CONCLUSIONS: This preliminary study suggests that EUS TCB can safely establish the diagnosis of AIP. Doing so helps guide management and may help to avoid unnecessary surgery. Prospective studies are needed to verify these findings and to more clearly define the role of EUS TCB in these patients.

Aged↗
PubMed2005

Assessment of the impact of an educational course on knowledge of appropriate EUS indications.

BACKGROUND: The knowledge level of EUS among gastroenterologists likely influences the appropriateness of requested indications for EUS. It remains unknown what the impact is of a short EUS course, involving didactic teaching, on knowledge levels of EUS indications for EUS. The aim of this study was to assess the impact of a 3-day educational course on knowledge levels of attending gastroenterologists regarding the appropriateness of indications for EUS. METHODS: A questionnaire was designed that tested knowledge of indications for EUS in 4 anatomic sites: esophagus, gastroduodenum, hepatopancreatobiliary system, and colorectum. This questionnaire was distributed to all attendees of a 3-day EUS educational course. All attendees completed the survey before and immediately after the course. RESULTS: A total of 24 gastroenterologists completed the pre- and post-course survey. Before the course, respondents scored highest in questions on EUS applications in the gastroduodenum (94%) and the hepatopancreatobiliary system (88%) compared with the esophagus (72%) and the colorectum (74%). Statistically significant improvements in knowledge were recorded in all organ categories: gastroduodenum (100%, p = 0.002 vs. pretest score), hepatopancreatobiliary system (99%, p < 0.0001), esophagus (92%, p < 0.0001), and colorectum (93%, p = 0.0004). The biggest improvement was observed in knowledge levels for the esophagus (20%) and the colorectum (18%). CONCLUSIONS: There was a consistent improvement in the gastroenterologists' knowledge levels of EUS indications among all organ categories after an educational course. Our findings suggest that education enhances gastroenterologists' understanding of EUS. Future studies should seek to assess the impact of these improved knowledge levels on the appropriateness of EUS referral patterns.

Clinical Competence↗
PubMed2005

Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors.

BACKGROUND & AIMS: Nonoperative methods for diagnosis of pancreas cysts often lack sufficient accuracy. Accurate diagnosis is needed to determine prognosis and guide clinical management. The aim of this study was to determine whether the tissue obtained by endoscopic ultrasound-guided trucut biopsy (EUS TCB) is sufficient for histologic diagnosis of cystic pancreatic tumors (CPTs). METHODS: EUS TCB was performed in patients with a suspected CPT. A dedicated gastrointestinal pathologist reviewed the core biopsies. The final diagnosis was based on clinical, laboratory, imaging, and biopsy findings, and resected specimens when available. RESULTS: EUS TCB was performed in 10 patients with a suspected CPT. Final diagnoses included serous cystadenoma (SCA, n=5), islet cell tumor (n=2), mixed seromucinous lesion (n=1), polycystic disease of the pancreas (n=1), and pseudocyst (n=1). EUS TCB was nondiagnostic in 3 of 10 patients. Among the other 7 patients, TCB diagnosed 4 SCAs, obviating the need for planned surgery in 3 patients. In the fourth patient with an SCA, the TCB result ruled out metastatic disease from locally recurrent lung cancer, allowing a narrowed radiation field. EUS TCB confirmed the need for surgery in 2 patients with an islet cell tumor. In 1 patient, EUS TCB findings were "partially" diagnostic, leading to previously unplanned surgery. CONCLUSIONS: This report establishes the capability and safety of EUS TCB to collect sufficient tissue for diagnosing CPTs. The results might help guide clinical management.

Adenoma, Islet Cell↗
PubMed2005

A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms.

BACKGROUND & AIMS: Endoscopic biliary sphincterotomy has complication rates of 5%-12%. The output from the electrosurgical generator may influence the degree of coagulation and the rapidity of the incision, and thus rates of pancreatitis, hemorrhage, and perforation. Some modern generators incorporate feedback control to standardize output and automate the alternating cut and coagulation modes. Our aim was to compare 2 feedback-controlled generators, one with constant pure cutting-type output and the other with an alternating cut and coagulation mode. METHODS: In this multicenter randomized study, 133 patients were assigned to the alternating cut/coag output and 134 patients were assigned to constant pure-cut output. Patients were stratified by their risk for pancreatitis. RESULTS: The overall pancreatitis rate was 1.5%, including 3 patients in the cut/coag group and 1 patient in the pure-cut group (P>.05). There were 11 poorly controlled (zipper) incisions in the pure-cut group and none in the cut/coag group (P=.02). The incision was completed in all patients without stalling. Immediate hemorrhage occurred in 35 pure-cut patients and 8 cut/coag patients output (P=.002). There were no episodes of clinically significant bleeding, delayed bleeding, or perforation. CONCLUSIONS: Biliary sphincterotomy using feedback-controlled generators results in dependable progression of incision with a low pancreatitis rate. Control of the incision is improved subjectively with the cut/coagulation output, but this did not translate into a difference in clinically significant complications.

Adult↗
PubMed2005

Clinical implications of the extent of invasion of T3 esophageal cancer by endoscopic ultrasound.

BACKGROUND: Endoscopic ultrasound (EUS) is an accurate imaging modality for local staging of esophageal cancer. We aimed to determine if depth of tumor invasion beyond muscularis propria (MP), as determined by preoperative EUS, is predictive of tumor recurrence or survival (a positive change in mortality) in patients with T3 esophageal cancer. METHODS: Records and images of all patients with T3 N1 M0 esophageal cancer staged with EUS at our institution between January 1999 and October 2003 were reviewed. EUS images were independently reviewed by five blinded endosonographers and tumors were classified as minimally invasive (invasion < 3 mm beyond MP) or advanced (invasion > or = 3 mm beyond MP) T3 disease. RESULTS: One hundred and sixty-five patients with esophageal cancer underwent EUS for staging and 39 patients with T3 N1 esophageal cancer were identified; 17 patients had minimally invasive T3 disease and 22 had advanced disease. All patients underwent neoadjuvant chemoradiation therapy followed by esophagectomy. Median follow up was 13 months. Adjusting for age and sex, minimally invasive disease was not associated with a statistically significant improvement in recurrence-free survival (hazard ratio, 1.45; 95% CI, 0.88-2.41, P = 0.14) or mortality (hazard ratio, 0.96; 95% CI: 0.49-1.78, P = 0.91). CONCLUSIONS: The extent of invasion of T3 esophageal cancer beyond MP, as determined by EUS, is not a significant predictor of tumor recurrence or mortality.

Combined Modality Therapy↗
PubMed2004

Intestinal endometriosis: the great masquerader.

Chronic symptoms of abdominal pain and irregular bowel habits in women evoke a broad differential diagnosis including irritable bowel syndrome, infection, malabsorption, and inflammatory bowel disease. Endometriosis, a common disorder in young women that can involve the intestinal tract, deserves consideration as well. Intestinal endometriosis is typically asymptomatic; however, when symptoms occur, they can mimic those of irritable bowel syndrome. Identifying intestinal endometriosis can be challenging, but historical points and key clinical features aid in diagnosis.

Diagnosis, Differential↗
PubMed2004

Complications of temporary pancreatic stent insertion for pancreaticojejunal anastomosis during pancreaticoduodenectomy.

BACKGROUND: Morbidity associated with pancreaticoduodenectomy usually results from complications associated with the pancreaticojejunal anastomosis, in particular, a pancreatic leak. Four patients with retained transanastomotic pancreatic stent-induced complications after pancreaticduodenectomy were identified. METHODS: Medical records for the 4 patients were reviewed, and telephone interviews were conducted. OBSERVATIONS: Each patient underwent pancreaticoduodenectomy for a peripapillary tumor with creation of a pancreaticojejunal anastomosis by using an internal 8F Silastic stent. Subsequent evaluation for steatorrhea (n=3) or recurrent pancreatitis (n=1) led to discovery of a retained pancreatic stent. In one patient, the stent was incidentally discovered. Steatorrhea significantly improved (n=1) or resolved (n=2) after stent removal. The patient with pancreatitis has not experienced another episode. CONCLUSIONS: The possibility of a retained stent should be considered in patients presenting with steatorrhea or pancreatitis after pancreaticoduodenectomy.

Adult↗
PubMed2004

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States.

BACKGROUND: The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. METHODS: A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. RESULTS: Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. CONCLUSIONS: EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

Acute Disease↗
PubMed2004

Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists.

BACKGROUND: The level of awareness among non-gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice. METHODS: A questionnaire was designed that tested knowledge of the indications for EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary system and colorectum. The questionnaire was distributed by electronic mail to gastroenterologists, general internists, non-gastroenterologist subspecialists, and surgeons in a large multispecialty practice. RESULTS: The survey was distributed to 659 attending physicians of whom 227 (34%) replied: gastroenterologists (53%), internists (30%), non-gastroenterologist specialists (33%), and surgeons (28%). Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001). Among all non-gastroenterologists, knowledge of indications for hepatopancreatobiliary (mean 66.3% correct responses) and colorectal applications (64.0%) was inferior to knowledge of esophageal (71.5%) and gastroduodenal (83.5%) applications. CONCLUSIONS: Internists, non-gastroenterologist specialists, and surgeons in a large multispeciality practice have moderate knowledge of the indications and the utility of EUS. Knowledge was at the lowest level for hepatopancreatobiliary and colorectal applications of EUS for all 3 groups of non-gastroenterologists. Future studies should focus on the education of non-gastroenterologists regarding the role of EUS and assess the impact of such education on the appropriateness of EUS referral patterns.

Bile Ducts↗
PubMed2004

Evaluation and management of cystic pancreatic tumors: emphasis on the role of EUS FNA.

Cystic lesions of the pancreas are increasingly recognized and usually represent pseudocysts or cystic pancreatic tumors (CPTs), but also include congenital cysts, acquired cysts, extrapancreatic cysts, or cystic degeneration of solid tumors. It is important to distinguish CPT lesions given their varied prognosis and therapy. Mucinous varieties of CPTs (mucinous cystic neoplasms and intraductal papillary mucinous tumors) are premalignant or malignant, and surgical resection is generally recommended in good operative candidates. In contrast, nonmucinous CPTs include serous cystadenomas with a very low malignant potential, or pseudocysts, which are always benign. As a result, nonmucinous CPTs are generally resected only when inducing symptoms or complications. Review of the clinical, imaging, laboratory, and pathology information may clarify the specific tumor type. The relatively limited accuracy of any one modality requires that we consider the combined results when making management decisions.

Biopsy, Fine-Needle↗
PubMed2004

Pancreatic mucinous cystic neoplasm defined by ovarian stroma: demographics, clinical features, and prevalence of cancer.

BACKGROUND & AIMS: Pancreatic mucin-producing cystic neoplasms are classified into 2 distinct entities: mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN). In previous studies, MCN often has been defined loosely and has not always been distinguished clearly from IPMN. Our aims were to determine the demographics, clinical features, and prevalence of invasive cancer in MCN defined by the presence of characteristic ovarian stroma. METHODS: By using the presence of ovarian stroma as a requisite criterion for diagnosis of MCN, a single pathologist, unaware of clinical information, identified 56 MCNs from 243 mucin-producing neoplasms resected at Mayo Clinic between 1986 and 2003. Medical records of the MCN patients were reviewed to obtain clinical and demographic data. RESULTS: Patients with MCN were almost exclusively (98%) women; we identified 1 man with a neoplasm containing ovarian stroma. The mean (+/-SD) age at resection was 48 +/- 15 years (84% < 60 y). Abdominal pain was the most common presenting symptom; 16% were asymptomatic. Most MCN (93%) were in the pancreatic body/tail region. Their median size was 5 cm (61% > or =5 cm). Histologically, 50 (89%) were adenomas, 2 (4%) had carcinoma-in-situ, and 4 (7%) had invasive cancer. None of the 22 MCNs <5 cm in size had invasive cancer. No patient with noninvasive disease had a recurrence after resection. CONCLUSIONS: MCN defined by ovarian stroma has a distinct demographic and clinical profile and a low prevalence of invasive cancer. These observations suggest that ovarian stroma should be used as the defining criterion for diagnosing MCN.

Adenocarcinoma, Mucinous↗
PubMed2004

Clinical implications of quantification of mesorectal tumor invasion by endoscopic ultrasound: All T3 rectal cancers are not equal.

BACKGROUND: Depth of invasion beyond the muscularis propria (MP) by T3 rectal cancer can vary. The purpose of the present paper was to determine if depth of invasion beyond MP, as assessed by preoperative endoscopic ultrasound (EUS), can predict tumor recurrence in patients with T3 rectal tumors. METHODS: Patients with T3NxM0 rectal cancer, as determined by EUS, who underwent surgical resection (without preoperative neoadjuvant therapy) were reviewed by two blinded endosonographers. Tumors were classified as minimally invasive T3 (invasion </= 2 mm beyond MP by EUS) and advanced T3 disease (invasion > 2 mm). RESULTS: Forty-two patients with T3 rectal tumors underwent surgical resection without receiving preoperative neoadjuvant therapy, of whom 14 had minimally invasive T3 and 28 had advanced T3 disease, as determined by preoperative EUS. Median follow up was 19 months. Tumor recurrence rates in minimally invasive and advanced T3 tumors were 14.3% and 39.3%, respectively, P = 0.02 (log-rank test). Adjusting for nodal status and postoperative adjuvant therapy administration, Cox proportional hazards model demonstrated advanced T3 disease (by EUS) to predict tumor recurrence, hazard ratio, 2.28 (95% confidence interval: 1.17-5.81), P = 0.01. CONCLUSIONS: All T3 rectal tumors are not equal, with minimally invasive disease carrying a more favorable prognosis. By discriminating minimally invasive from advanced T3 disease, preoperative EUS provides important prognostic information. Further subclassification of T3 tumors, based on preoperative EUS staging, should be considered to enhance selection of patients for neoadjuvant therapy.

Aged↗
PubMed2004

A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures.

BACKGROUND AND AIM: The aim of this study was to assess the relative sensitivities and specificities of fluorescence in situ hybridization (FISH) and routine cytology for the detection of malignancy in biliary tract strictures. METHODS: Bile duct brushing and aspirate specimens were collected from 131 patients being evaluated for possible malignant bile duct strictures. Both specimen types were assessed by FISH but only brushing specimens were assessed by cytology. The FISH assay used a mixture of fluorescently-labeled probes to the centromeres of chromosomes 3, 7, and 17 and chromosomal band 9p21 (Vysis UroVysion) to identify cells having chromosomal abnormalities. A case was considered positive for malignancy if five or more cells exhibited polysomy. RESULTS: Sixty-six of the 131 patients had surgical pathologic and/or clinical evidence of malignancy. Thirty-nine patients had cholangiocarcinoma, 19 had pancreatic carcinoma, and 8 had other types of malignancy. The sensitivity of cytology and FISH for the detection of malignancy in bile duct brushing specimens in these patients was 15% and 34% (p < 0.01), respectively. The sensitivity of FISH for the bile aspirate specimens was 23%, and the combined sensitivity of FISH for aspirate and brushing specimens was 35%. The specificity of FISH and cytology brushings were 91% and 98% (p= 0.06), respectively. CONCLUSIONS: FISH is significantly more sensitive than and nearly as specific as conventional cytology for the detection of malignant biliary strictures in biliary brushing specimens. FISH may improve the clinical management of patients who are being evaluated for malignancy in bile duct strictures.

Adolescent↗