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Gavin C Harewood

Publications and source records attributed to Gavin C Harewood.

At least 19 recordsLinked to original sources
PubMed2006

Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma.

BACKGROUND: EUS-guided FNA (EUS-FNA) is the most accurate method for lymph-node staging of esophageal carcinoma; however, it may not be necessary when EUS features are present that strongly suggest a benign or a malignant origin. AIMS: (1) To identify a combination of EUS criteria that have a sufficient sensitivity and specificity to preclude the need for EUS-FNA and (2) to assess the cost savings derived from a selective EUS-FNA approach. METHODS: A total of 144 patients with esophageal carcinoma were prospectively evaluated with EUS. Accuracy of standard (hypoechoic, smooth border, round, or width > 5 mm) and modified (4 standard plus EUS identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) criteria were compared (receiver operating characteristic curves). Resource utilization of two diagnostic strategies, routine (all patients with lymph nodes) and selective EUS-FNA (FNA only in those patients in whom the number of EUS malignant criteria provides a sensitivity and a specificity <100%), were compared. RESULTS: Modified EUS criteria for lymph-node staging were more accurate than standard criteria (area under the curve 0.88 vs. 0.78, respectively). No criterion alone was predictive of malignancy; sensitivity and specificity reached 100% when a cutoff value of >1 and >6 modified criteria were used, respectively. The EUS-FNA selective approach may avoid performing FNA in 61 patients (42%). CONCLUSIONS: Modified EUS lymph-node criteria are more accurate than standard criteria. A selective EUS-FNA approach reduced the cost by avoiding EUS-FNA in 42% of patients with esophageal carcinoma. These results require confirmation in future studies.

Adult↗
PubMed2006

International survey of knowledge of indications for EUS.

BACKGROUND: The knowledge level for EUS indications among gastroenterologists across different locations and practices is not known. The aim of this study was to assess knowledge of EUS indications among a diverse group of gastroenterologists, both nationally and internationally. METHODS: A web-based survey was designed to assess knowledge of EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary, and colorectum. The survey was distributed by electronic mail (e-mail) to members of the American Society for Gastrointestinal Endoscopy. RESULTS: The survey was distributed to 3848 physicians, of whom 2848 had an active e-mail address. There were 323 respondents (11.3%), of whom 210 were U.S. members and 113 international. Overall, the mean score for the different organ systems for all respondents was highest for gastroduodenum (93% correct) and lowest for colorectum (71%) compared with esophagus (79%) and hepatopancreatobiliary (83%) systems. The mean total score was higher for U.S. respondents (84% correct) compared with international respondents (79%, p < 0.0001). Endosonographers fared better than those who were not endosonographers (85% vs. 81%, p = 0.0002). CONCLUSIONS: Knowledge levels of colorectal applications of EUS are poorest among the 4 organ systems studied. Future educational initiatives should focus on applications of EUS in this category. Studies are required to assess the impact of this education on the appropriateness of EUS referral patterns.

Bile Ducts↗
PubMed2006

Abdominal CT as a predictor of outcome before attempted direct percutaneous endoscopic jejunostomy.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) placement succeeds in 72% to 86% of attempts. Failure is most often because of inadequate transillumination or gastroduodenal obstruction. Even in failed cases, patients are exposed to the risks of anesthesia, exploratory percutaneous needle punctures, and the cost burden of suboptimal resource utilization. Hence, a preprocedure predictor of outcome would be useful. OBJECTIVE: To evaluate whether review of clinically available abdominal CTs can predict the outcome of subsequent DPEJ attempts. DESIGN: Retrospectively conducted blinded review of abdominal CTs performed within 30 days before attempted DPEJ. Objective anatomic features potentially pertinent to DPEJ success were scored, and a prediction of the anticipated procedural outcome was made. SETTING: A large tertiary referral center. PATIENTS: A total of 115 patients who underwent attempted DPEJ and who also had an abdominal CT in the preceding 30 days. MAIN OUTCOME MEASUREMENTS: Reviewer's overall prediction of success, 3 objective anatomic measurements. RESULTS: For the overall prediction of success, a CT performed poorly, with a sensitivity of 60%, a specificity of 53%, a positive predictive value of 71%, and a negative predictive value of 40%. Mean abdominal-wall thickness was significantly greater in the failures than the successes (27 vs 21 mm, P = .02), and just 39% of the procedures in patients with an abdominal-wall thickness >3 cm were successful. LIMITATIONS: Retrospective. CONCLUSIONS: Failed DPEJ attempts were associated with greater patient abdominal-wall thickness, and this should be taken into consideration before attempted DPEJ. Otherwise, review of existing abdominal CTs appears to have limited utility in predicting DPEJ outcome.

Abdominal Wall↗
PubMed2006

Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding.

INTRODUCTION: Endoscopic obliteration of esophageal varices by endoscopic variceal ligation (EVL) is an effective form of secondary prophylaxis. However, there is no consensus regarding the technical aspects of EVL for secondary prophylaxis. The present study compares the technical aspects of EVL (frequency of sessions, number of sessions and number of bands used) in patients who rebled following secondary prophylaxis of esophageal varices by EVL compared to those who did not rebleed. METHODS: All patients who underwent EVL for treatment of acute variceal bleeding followed by EVL for secondary prophylaxis and who subsequently developed recurrent variceal bleeding at Mayo Clinic, Rochester between January 1995 and May 2003 were identified. A control group of patients undergoing EVL for secondary prophylaxis who did not rebleed was identified. RESULTS: During the study period, 216 patients with acute esophageal variceal hemorrhage underwent emergent EVL treatment with follow-up EVL for secondary prophylaxis, of whom 20 (9.3%) subsequently rebled. Both rebleeding and non-rebleeding patient groups were well-matched with respect to liver function (Child-Pugh class), number and size of variceal trunks, endoscopic stigmata of hemorrhage and beta-blocker usage. The median interval between EVL sessions in the rebleeding group (2 weeks, interquartile range 0-2 weeks) was significantly shorter compared to the non-rebleeding group (5 weeks, interquartile range 3-7 weeks; P = 0.004). Adjusting for age, gender, and Child-Pugh class, interbanding interval >/= 3 weeks was associated with increased likelihood of not rebleeding, hazard ratio 3.84 (95% confidence interval: 1.69-11.79; P = 0.0007). CONCLUSIONS: These findings demonstrate the importance of technical aspects of EVL on patient outcome, suggesting the benefit of longer interbanding intervals. Future prospective studies are required to define the optimal intersession interval. Standardizing procedural aspects of EVL will aid in objectively evaluating the benefit of this procedure when compared to other modalities such as medical treatment.

Acute Disease↗
PubMed2006

Incident rates of colonic neoplasia in older patients: when should we stop screening?

INTRODUCTION: Current guidelines endorse colon cancer screening every 5-10 years in patients over 50 years of age. However, there is no consensus regarding what age is appropriate to stop screening. The aim of this study was to characterize neoplasia occurrence/recurrence in a large cohort of patients > or =70 years of age undergoing colonoscopy. METHODS: The Mayo Rochester endoscopic database was reviewed to determine the incidence of colonic neoplasia in patients > or =70 years undergoing two colonoscopies at least 12 months apart between January 1996 and December 2000. Patients were classified based on (i) age: 70-74, 75-79, > or =80 years; and (ii) polyp detection on initial examination, that is, subsequent examination for screening or surveillance. RESULTS: Overall, 1353 patients underwent two colonoscopies at least 12 months apart (median interval 140 weeks) with removal of polyp on initial examination in 726 (53.7%) patients (surveillance cohort). On subsequent endoscopy, polyps > or =10 mm were detected in 54 (4.0%) and cancer in 13 (1.0%) patients. All age groups were well matched with respect to detection of neoplasia on index examination (P = 0.9) and polyp size on initial colonoscopy among the surveillance group (P = 0.9). Using a Cox proportional hazards model, adjusted hazard ratios (95% confidence interval [CI]) for neoplasia (polyps > or =10 mm) were: 2.0 (1.50-2.73, P < 0.0001) (surveillance vs screening), 1.33 (0.96-1.79, P = 0.08) (> or =80 vs 70-74), and 1.05 (0.78-1.38, P = 0.75) (75-79 vs 70-74). Adjusted hazard ratios for development of cancer were: 1.87 (1.03-3.97, P = 0.04) (surveillance vs screening), 1.73 (0.84-3.56, P = 0.13) (> or =80 vs 70-74), and 1.38 (0.71-2.77, P = 0.34) (75-79 vs 70-74). CONCLUSIONS: Prior history of neoplasia remains a strong risk factor for colorectal neoplasia development in elderly patients and should be considered when deciding the need for continuing screening/surveillance. Incident neoplasia rates in a previously screened elderly population rise slowly with advancing age although cancer rates rise more sharply. Therefore, screening still retains a role in elderly patients; however, clinical judgment is still required to individualize screening practice. As the risk of competing comorbid illnesses continues to increase over time, the threshold to perform colon screening should increase accordingly.

Aged↗
PubMed2005

Relationship of colonoscopy completion rates and endoscopist features.

The success rate for reaching the cecum has been widely discussed as an indicator of technical expertise for colonoscopy. However, few studies have addressed the impact of endoscopist-specific parameters on cecal intubation rates. The aim of this study was to characterize the relationship between endoscopist-specific parameters (age, gender, experience level, annual procedure volume, insertion and withdrawal times) and cecal intubation rates for colonoscopy. Procedural data from all colonoscopies performed by gastroenterologists at the outpatient endoscopy unit of Rochester Methodist Hospital, Minnesota, between January and December 2003 were reviewed. Procedural data of 45 endoscopists who performed 17,100 colonoscopies over the study period were analyzed. The average cecal intubation rate was 93.9% (SD, 2.9%). Higher experience level (>9 years [median]) was significantly predictive of a cecal intubation rate >94% (OR = 3.43; 95% CI, 1.03-12.29; P = 0.04). Although higher procedure volume was not predictive of higher colonoscopy completion rates overall, when analysis was confined to the junior faculty members (<5 years' experience), completion rates for those endoscopists doing >200 per year (92.5%) was significantly higher than for those doing <200 per year (88.5%; P = 0.04). Our observations suggest that cecal intubation rates increase with increasing endoscopist experience. Moreover, among junior endoscopists, an annual volume of at least 200 procedures appears to be required to maintain adequate competence. Future prospective studies should provide data to support consensus guidelines recommending minimum annual procedure numbers required for maintenance of endoscopic competence among trained endoscopists.

Adult↗
PubMed2005

Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla.

BACKGROUND: Tumors that arise in the region of the major duodenal papilla account for 5% of GI neoplasms and 36% of resectable pancreaticoduodenal tumors. There is limited published literature that addresses the safety of endoscopic excision of the papilla. Although there is consensus about prophylactic pancreatic-duct stent placement, there is little supporting prospective data. The aim of this randomized, controlled trial was to compare the rates of postsnare ampullectomy pancreatitis in patients who did/did not receive prophylactic pancreatic-duct stent placement. METHODS: Consecutive patients who were to undergo en bloc snare ampullectomy were randomized to placement of pancreatic-duct stent after ampullectomy or to no stent placement. RESULTS: In total, 19 patients were enrolled, and 10 received pancreatic stents. Postprocedure pancreatitis occurred in 3 patients in the 24 hours after endoscopy, all cases occurred in the unstented group, 33% vs. 0% (stented group), p = 0.02. Median peak amylase level was 3692 U/L (range 1819-4700 U/L) and median peak lipase level was 11450 U/L (range 5900-17,000 U/L). All 3 patients were hospitalized for a median of 2 days (range 1-6), and all made a complete recovery. CONCLUSIONS: Our findings suggest that a protective effect is conferred by pancreatic stent placement in reducing postampullectomy pancreatitis. Future large-scale studies are required to confirm this benefit.

Adult↗
PubMed2005

Colonic biopsy practice for evaluation of diarrhea in patients with normal endoscopic findings: results from a national endoscopic database.

BACKGROUND: The colonic biopsy is the only reliable method for identification of microscopic colitis in patients with chronic diarrhea and normal endoscopic findings. METHODS: The Clinical Outcomes Research Initiative national endoscopic database was analyzed to determine the rate at which colonic biopsy specimens were obtained in patients undergoing colonoscopy for the evaluation of diarrhea with no visible mucosal abnormality. RESULTS: Between January 2000 and December 2003, 5565 unique adult patients underwent colonoscopy for evaluation of diarrhea without detection of any mucosal abnormality. Colonic mucosal biopsy specimens were obtained in 4410 (79.2%) of these patients. The rates at which biopsy specimens were obtained differed among the sites where colonoscopy was performed; biopsy specimens were obtained from more patients undergoing colonoscopy in university-affiliated settings (86.8%) compared with Veterans Affairs Medical Centers (VAMC) (78.5%) or community sites (78.6%) ( p < 0.001). On multivariate analysis, biopsy specimens were more likely to be obtained in younger patients (OR 0.7: 95%CI[0.6, 0.8] for age >50 years vs. <50 years), women patients (OR 1.4: 95% CI[1.2, 1.6] in community setting; OR 4.1: 95% CI[1.6, 10.5] in VAMC setting), and patients seen in university-affiliated medical centers (university center OR 2.1: 95% CI[1.5, 3.0] vs. community setting). CONCLUSIONS: Biopsy specimens are obtained in four fifths of patients with diarrhea and normal colonoscopy findings to exclude microscopic colitis. Variation in biopsy practice exists among endoscopy site types and by gender. Clear guidelines are needed for the endoscopic approach to these patients.

Adult↗
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↗