Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) has facilitated the diagnosis and treatment of pancreatobiliary diseases for a few decades. The procedure is relatively difficult to perform. One guideline indicates that to meet the minimum eligibility criteria to perform the procedure alone, a trainee should perform at least 180 to 200 ERCP under supervision. However, information about how to teach ERCP is sparse. Aims: To collect information that will help determine the optimal length of time that an attending physician should allow a trainee to cannulate the common bile duct (CBD). Methods: From October 2002 to March 2003, 4 ERCP fellows and from October 2003 to March 2004, another 4 ERCP fellows participated in the study. Each fellow had performed about 40 ERCPs under supervision prior to the study. During the first study period, we allowed each fellow to have 10 minutes for cannulation and in the second period 5 minutes. If the CBD could not be cannulated deeply within the time limits, an attending continued the cannulation attempts. We recorded the deep CBD cannulation time for each ERCP procedure as the time from the initiation the cannulation attempts until the time when the catheter was passed deeply into the CBD. The same 2 experienced pancreatobiliary-attending physicians participated in the study for both years. Results: In the first period, the fellows deeply cannulated 5 out of 45 patients. In the second period, fellows deeply cannulated 6 of 35 patients. The deep cannulation rate by the fellows in the 2 periods was not different (P>0.05). The mean deep CBD cannulation time was 30.24±16.3 minutes in the first period that was significantly longer than 15.1±13.2 minutes in the second period (P<0.01). Conclusions: For these small groups of relatively inexperienced fellows, attempts at cannulation longer than 5 minutes did not increase their cannulation rate and may result in a more difficult cannulation subsequently for the attending physician.

Ford, Ryan M MD; Affronti, John MS, MD; Cohen, Robert MD; Baumgarten, Deborah A MD, MPH; Cai, Qiang MD, PhD Author Information

Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a gastrointestinal endoscopic procedure that requires fluoroscopy. The radiation dose of fluoroscopy is much higher than that of routine X-ray examinations, such as a chest X-ray. A few studies regarding radiation exposure of patients and ERCP staff during ERCP have been published in recent years. However, information about radiation exposure during each step of the procedure is not well known.AIMS: This study aimed to provide data regarding radiation exposure during specific components of ERCP, such as during the deep cannulation of the common bile duct (CBD). Methods: In the last several months, patients referred to us for their first ERCP were enrolled in this study. The fluoroscopy time before, during and post deep cannulation of the CBD in each ERCP were recorded. Results: We analyzed 46 successful ERCP procedures during the study period. Those procedures can be divided into two groups: 18 were diagnostic ERCPs and 28 were therapeutic ERCPs. The latter included obtaining cytology, performing sphincterotomy, balloon extraction, and stent insertion, etc. The mean FT before deep cannulation of the CBD was minimal, less than 0.1 minutes for each procedure in both groups. The mean FTs during the deep cannulation of the CBD were 4.5±4.1 minutes and 6.4±7.9 minutes for the diagnostic group and the therapeutic group respectively. The mean FTs for the whole procedure were 6.1±5.0 minutes and 16.2±11.0 minutes for the diagnostic group and the therapeutic groups respectively. The FT during deep cannulation of the CBD accounted for a significant portion of the whole FT in both the diagnostic group (4.5/6.1, about 74%) and the therapeutic group (6.4/16.2, about 40%). Conclusions: The radiation dose of one-minute FT is approximately 15 mGy at skin entrance which is equal to almost 100 routine chest X-rays. If the cannulation time can be reduced thereby shortening the FT during deep cannulation of the CBD, it will significantly reduce the radiation exposure during ERCP.

CONTEXT:Conventional colonoscopy is the best available method for detection of colorectal cancer; however, it is invasive and not without risk. Computed tomographic colonography (CTC), also known as virtual colonoscopy, has been reported to be reasonably accurate in the diagnosis of colorectal neoplasia in studies performed at expert centers.OBJECTIVE:To assess the accuracy of CTC in a large number of participants across multiple centers.DESIGN, SETTING, AND PARTICIPANTS:A nonrandomized, evaluator-blinded, noninferiority study design of 615 participants aged 50 years or older who were referred for routine, clinically indicated colonoscopy in 9 major hospital centers between April 17, 2000, and October 3, 2001. The CTC was performed by using multislice scanners immediately before standard colonoscopy; findings at colonoscopy were reported before and after segmental unblinding to the CTC results.MAIN OUTCOME MEASURES:The sensitivity and specificity of CTC and conventional colonoscopy in detecting participants with lesions sized at least 6 mm. Secondary outcomes included detection of all lesions, detection of advanced lesions, possible technical confounders, participant preferences, and evidence for increasing accuracy with experience.RESULTS:A total of 827 lesions were detected in 308 of 600 participants who underwent both procedures; 104 participants had lesions sized at least 6 mm. The sensitivity of CTC for detecting participants with 1 or more lesions sized at least 6 mm was 39.0% (95% confidence interval [CI], 29.6%-48.4%) and for lesions sized at least 10 mm, it was 55.0% (95% CI, 39.9%-70.0%). These results were significantly lower than those for conventional colonoscopy, with sensitivities of 99.0% (95% CI, 97.1%->99.9%) and 100%, respectively. A total of 496 participants were without any lesion sized at least 6 mm. The specificity of CTC and conventional colonoscopy for detecting participants without any lesion sized at least 6 mm was 90.5% (95% CI, 87.9%-93.1%) and 100%, respectively, and without lesions sized at least 10 mm, 96.0% (95% CI, 94.3%-97.6%) and 100%, respectively. Computed tomographic colonography missed 2 of 8 cancers. The accuracy of CTC varied considerably between centers and did not improve as the study progressed. Participants expressed no clear preference for either technique.CONCLUSIONS:Computed tomographic colonography by these methods is not yet ready for widespread clinical application. Techniques and training need to be improved.

What a devastating thing to tell a patient! However diplomatically we try to say it (or sometimes avoid saying it) it leaves both the patient and endoscopist feeling terrible and in limbo. Many of us can find ourselves in this dilemma after endoscopically stenting a biliary stricture for a patient with painless jaundice. We figure that if we could just give them a definitive diagnosis, these patients could at least reach closure with this phase of their illness. We'd like to recommend and use an easy, quick, painless, and inexpensive method for making a diagnosis that's 100% accurate. We'd like to, but we can't.

INTRODUCTIONEUS is an accurate means of evaluating and diagnosing submucosal lesions of the GI tract. The aim of this study was to prospectively determine interobserver agreement for the EUS classification of submucosal masses among endosonographers with different levels of training and experience from multiple centers.METHODSTwenty patients with submucosal mass lesions diagnosed by upper endoscopy underwent EUS. Surgical findings were available for 16 patients. In 4 patients with obvious cystic/vascular structures (i.e., varices) no surgical specimen was necessary. A blinded observer developed a study videotape of critical endoscopic and EUS real-time imaging for each lesion. The videotape was distributed to 10 endosonographers, each with at least 1 year of experience, who independently reviewed the videotape and recorded their diagnosis based on EUS features. These endosonographers used previously agreed-upon standardized EUS diagnostic criteria for each category of lesion. A kappa (kappa) statistic, used to evaluate agreement, was calculated for each lesion category for the 10 endosonographers as a group and individually. An overall kappa statistic was also calculated. Significance was analyzed with a two-tailed t test.RESULTSAgreement was excellent for cystic lesions (kappa = 0.80) and extrinsic compressions (kappa = 0.94), good for lipoma (kappa = 0.65), fair for leiomyoma and vascular lesions (kappa = 0.53 and 0.54, respectively), and poor for other submucosal lesions (kappa = 0.34). Overall agreement among observers was good (kappa = 0.63). Furthermore, a significant association was noted between total years of EUS experience and the number of correct answers (p = 0.01).CONCLUSIONSInterobserver agreement is good for characterizing submucosal masses by EUS. However, it appears to be better for some lesions than others. The overall length of experience with EUS appears to play an important role in the accuracy of this modality in the evaluation of submucosal lesions.

Computerized endoscopic medical records can serve many functions including administration, scheduling, report generation, coding, billing, quality assurance, and correspondence. The ability to Tabled 1Summary TableCompanyCEMR productWebsiteFeaturesCompatible hardwareMinimum system requirementsCosts*Akron Systems Development/MeditracGI Trac 2000, GI Image, GI Voicewww.meditrac.comc-h,j,kAny manufacturerPentium 200 MHz, 64 MB RAM, 2 GB HD, Uninterruptable power supply, Windows NT 4.0 Workstation$18,400†cMoreGI Note, GI Image, GI Pathology, GI Online, GI Reviewwww.cMoremedical.coma-nAny manufacturerPentium 266 MHz, 64 MB RAM, 1 GB HD, CD-ROM, Windows 95/98/NT$45,000-$80,000CORICORIwww.cori.orga,c,e,f,l-nAny manufacturerPentium 75-450 Mhz, 16 MB RAM, Windows 3.1/95/98/NTFree‡DataMedicGI Station (Olympus Note GI)www.datamedic.comc,e,j,k,l,m,nAny manufacturerPentium 133 Mhz, 32 MB RAM, 1 GB HD, Windows 95/NT 4.0$30,000‡DictaMed SoftwareEndoprosewww.dictamed.comb,c,e,f,j,l-nAny manufacturerIBM Compatible, 16 MB RAM, Windows 95/98$4,000‡FujinonEF-101 Image Management Systemwww.fujinon.co.jpa,c-e,g,h,j,l-nFujinonFujinon Workstation$48,000-$60,000General Medical ApplicationsgCarewww.gmedcorp.coma-e,g,i-nAny manufacturerDigital Alpha or Pentium Class, 64MB RAM, 4GB HD, Windows NT$32,500-$44,500Olympus USAEndoworks, Image Manager Chart Note-GIwww.olympus.coma,c-e,g,h,j,nOlympusOlympus Workstation$52,630PentaxendoPro, Doc-U-Scribewww.pentaxmedical.coma,c-e,g,h,j,l-nPentaxPentax Workstation$29,300-$40,450Stenna Software SolutionsEndosuite 2000, SchedulePro, Suitenotes, SuiteTalk, SuiteSearchwww.stenna.coma,c-e,g,h,j-nAny manufacturerPentium, 32-64 MB RAM, PCI slot,10 Mpbs network transfer rate, Windows 95/98/NT$53,650Systrek Technologies Inc./ MedibossEndoscribe Image Capture 2www.mediboss.coma-h,j-mAny manufacturerPentium 200, 64 MB RAM, 2.5 GB HD free, multi-read CD-ROM, color printer$22,50–$27,025UtechEndosoftwww.utechproducts.coma-h,j-nAny manufacturerPentium 120, 64 MB RAM, 200 MB HD, Windows 95/NT, Color printer$41,500*Costs are for all necessary software and hardware to connect two endoscopy rooms and allow sharing of information from a common database (this requires a server in most cases). Information is current as of 10/1/99. †Cost does not include a server. ‡Cost includes software only. No hardware included.Key to Features: a-scheduling; b-patient monitoring; c-endoscopic report generation; d-image association; e-referral letter generation; f-pathology tracking; g-image import/export; h-image annotation; i-automated billing; j-networkable; k-procedural coding; l-practice management; m-quality assurance; n-clinical investigation. Open table in a new tab interface with other clinical systems may enhance exchange of endoscopic information. Limitations of current systems include cost, technical support, ease of use and networkability.

Biliary disease in the elderly patient presents unique diagnostic and therapeutic challenges to the generalist as well as the specialist. Diseases of this organ system are the leading indication for acute abdominal surgery in this age group. Since the number of persons over the age of 80 years has been predicted to increase at a rate five to six times that of the general population, an understanding of the unique characteristics of biliary disease in the elderly population is of increasing importance to clinicians.

INTEROBSERVER AGREEMENT AMONG ENDOSONOGRA]PEgERS FOR STAGING OF PANCREATIC CANCER BY ENDOSCOPIC ULTRASOUND. F. Gross, D. Ciaeeia, C. Schmitt, M. Catalano, J. Affrenfi, K. Binmceller, P. Stevens, T. Savides, M. Bhutani, L. RJcobein, N. Niekl, D. Faigel, J, Birk, C. Lightdale. Indiana Univemity Medical Center, University of TennesseeChattanooga Unit, St. Luke's Medical Center, University of Florida, University Hospital Hamburg, Columbia Presbyterian Medical Center, University of California at San Diego, Wright State University, University of Kentucky, Portland VAMC, Winthrop University HoepitaYSUNYStony Brook. Endoscopic Ultrasound (EUS) has been reported to be an accurate modality for staging panerentic cancer (CA). However, there is limited data regarding the effects of intembserver variation on the overall accuracy and clinical utility of EUS for staging pancreatic CA. AIM OF STUDY: To determine interobserver reliability for EUS staging of pancreatic tumors. METHODS: Twelve patients with previously diagnosed pancreatic duetal adenecarcinoma undenvent staging with EUS. Surgical correlation was obtained in aJl pafica'Rs. A blinded observer developed a study videotape of real-time EUS for each case. The videotape was then distributed to ten endosonograpbers with at least one year of previous experience who independently reviewed the tape and recorded their interpretation of the EUS tumor stage for eada case based upon previously reported EUS criteria for staging pancreatic CA. A multiple observer kappa (k) statistic was calculated for eneh staging category (T, N, and T+N), vascalar invasion and overall k. Kappa accounts for agreement due to chance alone and standardized ranges are available. The Light (G) statistie was utilized to allow for the presence of the gold standard. Accuracy was assessed using a simple matrix format. RESULTS: Overall agreement was highly statistically significant for T stage: k=0.22 ( G=5.52, Z=2.35, p<0.0l).Observers were more likely to agree with T3 stage tumors (94%) than 12 (40%) or T1 (33%) lesions. The Overall agreement for N stage was highly statistically significant: k=0.23 (G----4.44, Z=4.90, p<0.01). Agreement for absence of nodal involvement (63%) was better than that for the presence of nodal involvement (56%). For overall staging if+N): k=0.18 (G-=9.19, Z=4.98, p<.01). For vascular invasion: k------~.26 (G=-3.90, z=3.33, p<.01). The agreement for T and N stage improved as stage increased (p<0.01) and in the presence of vascular invasion (p<0.01). CONCLUSION: Interobserver agreement is good for staging pancreatic tumors by EUS. However, it appears to be better for some tumor stages than others. Experience may play a role in the successful use of this medality to evaluate pancreatic rumors.