Abstracts

a prior NOTES study) was calculated as a sum of 3 adhesion subscores: a) density/vascularity of adhesions: 0Znone; 1Zfilmy avascular; 2Zdense or vascular; and3Zdense and vascular; b) Size (width) of largest adhesive band: noneZ0;O4 cmZ3; and c) extent of adhesions: 0Znone, 1Z1 � 2-organ pair (e.g. celiac tostomach), 2Z2 � 2-organ pairs, 3Z3 or more 2-organ pairs.Results: All pigs thrived after EUS-guided celiac injection, with non-survivalpancreatic surgery at 6-14 days. All pancreatic surgeries were completedsuccessfully. Two of the 5 CPB pigs had adhesions that involved the pancreas insome way. Although the overall adhesion score was higher (Mann Whitneyp Z 0.06) in the CPN group (4.6) vs. CPB (0) vs. controls (0), there was norecorded interference with surgery (or vascular plane identification) in any of the3 groups, except minor interference in one CPB pig. Conclusions: A single celiacplexus (alcohol) neurolysis procedure, not surprisingly, causes peri-celiac adhesionformation; however, the adhesions do not appear to interfere with subsequentpancreatic surgery in a pig survival model. Celiac neurolysis may have a role inchronic.

Downstream financial benefits of EUS to a single medical centerMatthew AtkinsonPurpose: Endoscopic ultrasound (EUS) has proven to be a clinically valuableplatform. One possible barrier to more widespread use, however, is modestreimbursement rates relative to procedural time. We hypothesized that the numberof downstream procedures generated by EUS for a single institution would begreater than that produced by colonoscopy, and that this difference might offsetthe reimbursement advantage for colonoscopy.Methods: We retrospectively reviewed 920 consecutive EUS’s and 920 consecutivecolonoscopies at the University of Cincinnati (UC) to determine the downstreamprocedures generated for the institution within 18 months of the index procedure.A downstream procedure was included only if it was a direct result of the findingson the EUS or colonoscopy and if it would not have been performed at UC in theabsence of that EUS or colonoscopy. Further procedures that were performed afterthe original downstream procedure were excluded. Medicare Allowable Chargeswere assigned to actual CPT codes for endoscopic procedures, radiation oncology,and interventional radiology. Twenty of the surgeries were reviewed for actual CPTcodes and an average charge per surgery was generated. Average charges for eachchemotherapy regimen were also calculated. Medicare allowable charges forconsults were averaged between level 4 and level 5 visits and applied to all consults.Results: Overall, EUS led to a greater number of downstream procedures thancolonoscopy (218 vs. 62). EUS led to a greater number of surgeries and surgicalconsults than colonoscopy (63 vs. 25), a greater number of patients referred forchemotherapy (30 vs. 2), a greater number of patients referred for radiationtherapy (15 vs. 0), a greater number of patients referred for interventional radiologyprocedures (3 vs. 0), and a greater number of patients referred for endoscopicprocedures (107 vs. 35). Total downstream professional charges were greater forEUS than colonoscopy ($204,825.59 vs. $42,124.36). Professional charges created byEUS were greater for surgery ($82,731.68 vs. $33,060.50), for radiation oncology($25,718.70 vs. $0), for oncology ($23,229.13 vs. $0), for interventional radiology($3027.07 vs. $0), and for gastroenterology ($73,119.01 vs. $8,739.54). Totalphysician charges for the original 920 EUS’s was greater than the original 920colonoscopies ($324,241.85 vs. $209,805.73). Overall, total physician charges for the920 EUS’s and their downstream procedures was 2.1 times greater than totalphysician charges for the 920 colonoscopies and their downstream procedures($529,067.44 vs. $251.930.09).Conclusions: While reimbursement for a half-day of EUS is lower than a half-day ofcolonoscopy, the downstream procedures and professional charges generated byEUS for the institution appear to attenuate this difference.

Endoscopic ultrasound directed pseudocyst drainage without

the use of fluoroscopy: a case seriesKamran Ayub, D. Patterson, S. Irani, D. Schembre, M. Gluck,J. Brandabur, G. Jiranek, A. Ross, O. Lin, R. KozarekBackground & Aim: Endoscopic drainage of pancreatic pseudocysts is usuallyperformed using fluoroscopy and a therapeutic duodenoscope. Endoscopicultrasound (EUS) is often used to choose the puncture site and avoid penetratinga vessel. However, fluoroscopy and EUS equipment are typically in separate roomsmaking transport of EUS equipment difficult and cumbersome. Also, availability ofa fluoroscopy suite can be an issue at many institutions. The aim of this study wasto evaluate the technical feasibility and safety of EUS directed pseudocyst drainagewithout the use of fluoroscopy.Methods: Consecutive patients referred for pseudocyst drainage to oneendosonographer between July 2004 and November 2007 were managed by cystdrainage using EUS guidance without the use of fluoroscopy. Technical success rateand complications were reviewed. In addition, previous attempts at drainage wererecorded. Fifteen procedures were performed using the Olympus GF-UC140Pechoendoscope; one procedure was performed using the Suzi GFUCT160 therapeuticechoendoscope. In each case initial puncture was made using a 19-G needle and fluidwas aspirated. A .035 wire was passed through the needle into the cyst. The tract wasdilated over the wire using a 4.5 to 6 F graduated dilator; balloon dilation was then

S234 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009

performed to 8 or 10 mm. One to 4 stents were placed. Either 7 F x 3 cm or 5 cmdouble pigtail stents were used. An ERCP trained nurse was required for theprocedure. All procedures were performed only with an echoendoscope.Results: A total of 16 patients were managed with this technique. The procedurewas unsuccessful in one of 16 patients due to difficulty with sedation. Threepatients had previous failed attempts at cyst drainage by ERCP experts usingfluoroscopy and a therapeutic duodenoscope. EUS guided drainage was successfulin all three of these patients. There were 3 complications: one patient had delayedbleeding requiring transfusion; this patient was known to have varices in thepseudocyst. One patient had stent migration into the cyst; this was removed ata later date without any untoward consequences. A third patient had one of twostents slip out of the cyst due to initial wire loss; this was removed without anycomplications.Conclusions: EUS directed pseudocyst drainage without the use of fluoroscopyappears technically feasible and safe.

Wilkie’s syndrome diagnosed by curvilinear array endoscopy

ultrasound: an unsuspected entityDervis Bandres, Olaya Brewer, Olga Roman, Saturnino FernandezAim: The purpose of this case report is to show the feasibility of curvilinearendoscopic uitrasound (C-EUS) as a diagnostic tool in Wilkies syndrome.Case Report. Female patient, 17 YO, who was evaluated for postprandial epigastricdiscomfort since 2 years, with fullness, early satiety and nausea, no vomits,decreasing food ingestion with weight loss. Patient consulted to a paediatrician andnutritionist in different occasions without improving.Physical examination: BP 90/60 mmHg. Pulse 66 x min. Weight 34 kg. Height 1.56 m.BMI 13.99. No abdominal mass. No liver or spleen enlargement.Lab tests: abdominal ultrasound and upper barium swallow without abnormalities.An upper endoscopy was done finding an antral, 12 mm, sub epithelial lesion in thegreater curvature. She was referred for C-EUS, showing a lesion located in the deepmucosa. We evaluated the gallbladder, pancreas and liver without abnormalities.The Superior Mesenteric Artery (SMA) showed an angle of emergence of 18�

(normal O25�), suspecting a Wilkies syndrome. To confirm the diagnosis we madea CT scan angiography (GE multidetector scan) confirming the diagnosis.Recommendations to gain weight as specific position after food ingestion andhypercaloric diet were indicated. After 7 months of follow up, patient won 4 kg,improving 50% of her symptoms. Postprandial nausea persists, especially afterlunch.Conclusion: Wilkies syndrome is a rare condition with an incidence of 0.13 to 0.33%in barium swallows. Over 400 cases have been reported in the english literature. Toour knowledge this is the first case diagnosed by C- EUS. This is an excellenttechnique, not only for therapeutic but also for diagnostic purposes, allowing theendosonographer to diagnose rare and difficult conditions. As shown in this report,Wilkies syndrome should be kept in mind in those patients referred for EUS, withunspecific abdominal symptoms and low weight when other diagnostic methodshave failed. C-EUS may be easier and better than radial EUS or miniprobes for thediagnosis of this entity, since we can detail the emergence of the SMA from theAorta, measuring the angle and the distance between its posterior wall and theAorta’s anterior wall in an axial view.

Endoscopic ultrasound fine needle aspiration of solid

pancreatic lesions in a Venezuelan academic centerDervis Bandres, Olaya Brewer, Victor Bracho, Carolina Dıaz,Victoria Garcıa, Nelson SimonovichAim: The purpose of this study is to evaluate the diagnostic accuracy of endoscopicultrasound fine needle aspiration (EUS-FNA) of pancreatic solid lesions.Method: we searched our computer files all EUSFNAS of solid pancreatic lesionssince 2001, done by the same operator, with the Wilson Cook� needle USN 3 andthe Wilson Cook� Echotip 22G needle, with a Pentax� echoendoscope FG 32 UAwith a Hitachi� processor 405 Plus. Specimen adequacy was evaluated bya cytopathologist and then analyzed by a pathologist. Final diagnosis was obtainedby surgery, medical treatment or after a mean clinical follow up of 2 years, includingpatients who died of the disease. We calculated accuracy, sensitivity, specificity,positive and negative predictive value and likelihood ratio, with a 95% confidenceinterval. Data was analyzed with SPSS for windows version 15.0.Results: EUSFNAS were obtained in 89 patients, 56.2% women and 43.8% men,mean age 61 years. Lesions were mainly in the head of the pancreas (74%).According to the AJCC TNM staging system, 44.9% were categorized as T3 and37.1% as T4. Only 3.4% had a benign aspect. The EUSFNA yielded a cytologicaldiagnosis in 93% of patients (83/89). The WC USN 3 needle was used in 16 patients(2001-2004) and the WC Echotip 22G in 73 (2004-2008). Mean number of passeswas 2-4 (76.4%). Malignancies were the commonest (82%) and adenocarcinomathe most frequent. We found the final diagnosis in 43 patients of which 18 hadsurgery, 20 chemotherapy and 5 were observed. No complications werereported. There were 2 perforations of the scope with the WC USN3 needle.Overall, the accuracy, sensitivity, specificity, positive and negative predictive value

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