19G FNA Research Articles

Comparation of 5ml and 10ml Negative Pressures with Wet-suction Techniques for EUS-FNA of Solid Lesions: A Single-center Randomized Controlled Trial.

The negative pressure selectable for the wet-suction technique remains uncertain. The aim was to investigate the quality of sampling and diagnostic accuracy with solid lesions by 5mL and 10mL negative pressure with wet-suction techniques. This is a single-center, crossover, randomized controlled trial conducted with a random sampling technique. In all, 160 patients consecutively undergoing EUS-FNA for solid lesions were randomized in a ratio of 1:1 into 2 groups, the 5mL and 10mL negative pressure wet-suction group. The main outcome was to compare the sample quality between the 2 groups. The secondary outcome was to compare the histologic and cytologic diagnostic accuracy of solid lesions. Pancreatic (n=129) and nonpancreatic (n=27) lesions from 156 lesions were examined. The sample quality concluding cellularity, adequacy, integrity, and blood contamination were comparable between the 2 groups. However, in subgroup analysis, we found 19G FNA provided more integrity of specimen in 5mL than in 10mL group (100% vs. 82.9%, P=0.025). In contrast, this benefit was not noteworthy in the 22G FNA subgroup. And there was no statistically significant in histologic (87.82% vs. 87.18%, P=1.000) and cytologic (78.85% vs. 80.77%, P=0.778) accuracy between 5mL and 10mL groups. When using the wet-suction technique, 5mL and 10mL negative pressure offer equivalent sample quality and diagnostic accuracy. However, the 19G FNA can obtain better sample quality with 5mL negative pressure than 10mL negative pressure.

S2840 Hepatic Tuberculoma Caused by Mycobacterium Fortuitum: A Rare Case Diagnosed by EUS-FNA

Introduction: Mycobacterium fortuitum is a type of nontuberculous mycobacteria belonging to a group classified as Rapidly Growing Mycobacteria (RGM), along with Mycobacterium abscessus and Mycobacterium chelonae. M. fortuitum is predominantly associated with skin, soft tissue, and surgical-wound infections. Catheter-related sepsis and disseminated disease can also occur. Isolated liver involvement by atypical mycobacterial infection is exceedingly rare. Here we describe a case of M. fortuitum presenting as an asymptomatic liver mass. Case Description/Methods: A 67-year-old male was referred for endoscopic ultrasound (EUS) to evaluate a gastric body subepithelial lesion (SEL) and a 3 cm incidental liver mass. He was asymptomatic. Percutaneous CT-guided biopsy was performed, but pathologic results were nondiagnostic. Patient was thus referred for EUS to evaluate the gastric SEL and determine if the liver mass represented metastasis. A 14 by 4 mm elongated intramural hypoechoic mass arising from the muscularis propia highly suggestive of a leiomyoma or GIST was identified. A heterogeneous mass with cystic spaces and echogenic foci in the left liver lobe measuring 27 by 20 mm was sampled using a 22g FNA needle. Pathology revealed granulomatous inflammation with necrosis. An AFB stain was positive for acid fast bacilli. PCR analysis of the specimen detected M. fortuitum DNA. Patient was treated with levofloxacin 750 mg daily plus trimethoprim and sulfamethoxazole (Septra DS) 800 mg - 160 mg twice daily. Follow-up contrast-enhanced MRI revealed complete resolution of liver lesion after 3 months of antibiotics. Discussion: Isolated liver involvement by nontuberculous mycobacteria is uncommon, usually asymptomatic, and its diagnosis can easily be missed or mistaken. We report the first case of a hepatic tuberculoma caused by M. fortuitum diagnosed by EUS-FNA. Precise and accurate recognition by a minimally invasive technique via EUS-FNA resulted in prompt treatment and resolution of the disease.

Endoscopic Ultrasound-Guided Liver Lesions Biopsy with Atypical Malignancies- An Alternative to Radiological Biopsy

Background: Endoscopic ultrasound (EUS) is gaining attraction as an alternative method of obtaining biopsies. It offers a more targeted approach for focal lesions in liver especially for those areas which are accessible via EUS-guided method.
 Materials and Methods: A total of 8 patients underwent EUS-guided liver lesions biopsies (LLB). EUS Guided LLB was performed using the 22G FNA needle, 2 passes were done with slow pull technique over one minute with 10–15 strokes done in each pass to obtained core samples. The average duration of the procedures ranged from 15–30 minutes.
 Results: Out of 8 patients, majority were males. Most of these patients had presented with nonspecific signs and symptoms including weight loss, abdominal pain, jaundice etc. All of the 8 patients had an atypical liver lesions on initial radiological evaluation with inconclusive tumour markers and atypical CT radiological findings. Screening for Hepatitis B and C virus were negative in all of them. EUS guided biopsy performed in them revealed the following diagnosis: well differentiated adenocarcinoma, sarcomatoid carcinoma, neuroendocrine tumour, smooth muscle tumour, metastatic adenocarcinoma, lymphoproliferative disorder and malignant melanoma.
 Conclusions: EUS-guided LLB is an alternative new technique for biopsy of liver lesions with suspected atypical malignancies.

Pancreatic Solid Lesions Accompanied by Large Pseudocysts – How to Obtain a Histological Diagnosis

Background: Pseudocysts accompanying pancreatic solid lesions are rare findings and represent a big hurdle in obtaining a pre-operative histological diagnosis. Although they are usually complications of pancreatitis, pseudocysts can develop as a consequence of compression on the main pancreatic duct of solid masses whose characterization is essential. If the cyst is of moderate-large size, the acoustic effect of the fluid content and also the compression of the cyst itself on the pancreatic parenchima make often impossible to visualize the lesion which is squeezed too far from the probe to be seen. As a result, perfoming endoscopic-ultrasound guided fine needle aspiration/biopsy (EUS-FNA/B) of the solid mass underneath it is usually very challenging. Description of the technique: When there is a suspicion of a solid mass along with a moderate-large size pseudocyst, having a histological confirmation of cancer before surgery is essential and nowadays considered as standard of care. Using a 19G FNA needle to aspirate the cyst to dryness improves dramatically the lesion accessibility which becomes in the end visible and approachable with a standard EUS guided FNA or FNB. The procedure is safe and easy to perform under conscious sedation. Conclusions: EUS guided aspiration of large pseudocysts developed as complication of pancreatic lesions can be a crucial step in facilitating the histological confirmation of potential malignant lesions prior to surgery, allowing their visualization and biopsy.

ID: 3526877 ENDOSCOPIC ULTRASOUNG-GUIDED PORTAL VEIN SAMPLING OF CIRCULATING TUMOR CELLS IN PANCREATIC ADENOCARCINOMA – A PROSPECTIVE RANDOMIZED PILOT STUDY COMPARING A 22 AND 19-GAUGE (G) NEEDLE

Acquisition of circulating tumor cells (CTCs) may hold potential benefit for the management of patients with pancreatic adenocarcinoma (PDAC). Endoscopic ultrasound-guided portal vein sampling (EUS-PVS) has been recently proposed as a novel means to enhance acquisition of higher concentrations of CTCs in patients with PDAC versus peripheral blood sampling (PBS). However, the optimal and safest needle for PVS has not been defined. The aim of this study was to determine the technical feasibility, efficacy and safety of EUS-PVS for CTCs with a 22-G and 19-G FNA needle.

A loop‐shaped minimally invasive brush for improved cytology sampling of pancreatic cysts during EUS‐FNA

AbstractPancreatic cancer is the fourth leading cause of cancer‐related deaths in the West and has a 5‐year survival rate of only 2%–9%. Pancreatic cystic lesions are precursors of pancreatic cancers and a prime target for early diagnosis. Endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) enables collection of cystic fluid aiming for the diagnosis of malign and premalign cysts. However, this fluid is acellular or paucicellular in 20% of cases, hampering a proper diagnosis. Here, we introduce a minimally invasive Nitinol brush that can be operated through the 413 µm lumen of a 22G FNA needle. During operation, the brush is rotated against the inner wall of the cyst, removing cells and dispersing them in the cystic fluid, where they can be aspirated through the needle. We demonstrate the brush function using three models. An in vitro cyst model was used to visualize the brushing procedure and the mechanical interaction between the brush and the wall of a spherical cavity. Ex vivo porcine intestine and bovine ovary cyst models were used to demonstrate how brushing increases the number of harvested cells with more than one order of magnitude. These results indicate the potential of cystic brushing for the minimally invasive early diagnosis of pancreatic adenocarcinoma.

Su1315 DIFFERENCES IN THE DIAGNOSTIC YIELD BETWEEN EUS GUIDED FINE NEEDLE ASPIRATION (FNA) AND CORE BIOPSY (FNB) NEEDLES IN THE EVALUATION OF SUBEPITHELIAL LESIONS IN THE UPPER GASTROINTESTINAL TRACT

Establishing the histological diagnosis of subepithelial lesions (SEL) can be challenging. Even with rapid on-site cytology (ROSE), the diagnostic yield of EUS-FNA is low (40-65%) as core tissue is often required for ancillary studies such as immunohistochemistry (IHC) stain. Newer EUS-FNB needles are designed to obtain core tissue. This study aimed to compare the diagnostic yield of conventional FNA needles with the newer FNB needles in EUS guided tissue acquisition of SEL in the upper gastrointestinal tract. A prospectively collected database on all patients who were referred for EUS guided tissue acquisition of SEL in the upper GIT over 10 years was retrospectively reviewed. All EUS FNA/FNB procedures were performed without ROSE, and all material from the needles were placed into formalin for direct histological examination. The conventional group included specimens obtained from the 22G and 25G FNA needles and 25G reverse bevel needle. The FNB group included specimens from the 20G or 22G reverse bevel needle. The final diagnosis was based on either surgical specimens or from repeat FNA or FNB specimens with at least 6 months of clinical follow up. Specimens from 178 SEL taken from 166 patients, of which 100 were by FNB needles and 78 by FNA needles. There were no differences in demographics, lesion size and location of the lesion along the upper GIT tract between the group. The needle caliber used in each group as well as the diagnoses are summarized in Table 1. The diagnostic accuracy (86/100 vs 45/78; P<0.001) and ability of perform IHC (70/100 vs. 28/78; P<0.001) were substantially higher with FNB than FNA needles. The number of passes were similar in both groups (FNB=2.2± 0.8 vs 2.3±0.9; P=0.61). Of the non-diagnostic cases (n=47), 29 (61%) were smaller than 15mm, and were suspected to be lipomas (n=22), leiomyomas (n-18), pancreatic rest (n=5) or duplication cysts (n=2) based on EUS evaluation. No patients reported or were re-admitted due to pain, bleeding or perforation. Even with a similar number of needle passes and no ROSE, FNB needles achieved a higher diagnostic accuracy than FNA needles for EUS guided tissue acquisition of SEL, suggesting that FNB is the needle of choice for SEL.

1949 Modern Coils and Glue: An Evolving EUS Application in the Management of Gastric Varices

INTRODUCTION: Ethylene vinyl alcohol (EVOH) is a liquid embolic agent approved for cerebrovascular lesions. DMSO solvent dissipates into the blood, causing the EVOH copolymer and suspended tantalum to precipitate in situ into a spongy, coherent embolus. Their role in the management of gastric varices is still unknown. We are presenting our experiences with this novel echoendoscope (EUS) guided use of EVOH to achieve gastric variceal obturation (GVO). CASE DESCRIPTION/METHODS: Case 1 : 44-year-old male with decompensated cirrhosis presented with melena. EGD showed large gastric varix (GOV-2). EUS- guided coiling and EVOH glue injection was planned. Gastric varices were identified using a linear echoendoscope at 7.5 MHz and 22G FNA needle was then advanced into varix with position confirmed by aspirating blood. Three embolization microcoils (5 mm/mm2, 8 mm/4mm, 7 mm/3mm; proximal end diameter/distal end diameter) were placed into the varix followed by needle flush with a 0.8 ml DMSO (dimethyl sulfoxide). Post DMSO flush, 5 mL EVOH glue was injected with excellent flow reduction on EUS doppler. 0.8 ml of DMSO was again used to flush the needle. Patient tolerated procedure well and had no signs of bleeding prior to discharge. Case 2 : 39-year-old male with history of alcoholic and HCV cirrhosis and hepatocellular carcinoma, two prior banding procedures for bleeding esophageal varices, gastric varices, presented with signs and symptoms of decompensated cirrhosis, hematemesis and melena. EGD with banding was done for large esophageal varices with stigmata with successful hemostasis. Large gastric varix (GOV-1) was also discovered. Coiling and glue was injected with similar EUS guided technique as above (sixteen embolization microcoils of varying sizes (8 mm/4 mm, 7 mm/3 mm, 5 mm/2 mm); 3 mL EVOH glue injection). Post procedural EUS doppler imaging showed excellent flow reduction. DISCUSSION: EVOH is well-known as catheter based embolic therapy for neurovascular lesions. Its application under EUS image guidance for gastric varices has not been reported yet to our knowledge thus making our case as unique. However larger, prospective multicenter trials with EVOH will be required to study rebreeding rates and long-term outcomes in the management of gastric varices.

929 A Prospective Evaluation of a Novel Ultra-Slim Echoendoscope for EUS-Guided FNA, FNB and Celiac Plexus Neurolysis

INTRODUCTION: Safe and successful EUS and EUS-guided interventions rely on the ability to reach the intended organ reliably and safely. Possible barriers include altered anatomy, stenosis in the GI tract, or low BMI, making the current echoendoscopes hazardous to use. Therefore, we prospectively evaluated the utility of a novel Ultra-Slim echoendoscope in these challenging scenarios. METHODS: We prospectively enrolled 25 patients in this study. Criteria for inclusion were as follows: Weight less than 120 lbs, children, mediastinal lymph nodes with severe lung disease or sleep apnea, altered anatomy, and esophageal stenosis precluding the passage of the standard echoendoscope. The Ultra-Slim echoendoscope (EG-3270UK: Pentax, Montvale, NJ USA) was utilized in all cases. A 22-gauge FNA or FNB needle were utilized. A fenestrated 20-gauge needle was used for CPN. Complications were assessed at 30 days as we previously described. RESULTS: A total of 25 patients were included in this study with a mean age of 69.16 years (standard deviation of 13.5). Females accounted for 64% of the study population. Indications for EUS use were: 64% (n = 16) had an abnormal CT or PET scan, 4% (n = 1) had MLN, 24% (n = 6) had a pancreatic mass, 8% (n = 2) had other indications. Reasons for using the Ultra-slim echoendoscope were: 28% of patients (n = 7) had low body weight defined as less than or equal to 120 lbs, 12% (n = 3) had MLN, 32% (n = 8) had altered anatomy and 28% (n = 7) had esophageal stenosis. Of the 25 Ultra-slim procedures performed, an FNA biopsy was taken 68% of the time (n = 17) while in 32% (n = 8) a biopsy was not performed. Of those 17 biopsies taken, a 22G FNA needle was used 87.5% (n = 14) of the time, and the FNB 19G needle was used 12.5 % (n = 2). Targets for biopsy were MLN 56.25% (n = 9), Adrenal Gland 6.25% or (n = 1), Liver 18.75% (n = 3), Pancreas 12.5% (n = 2) or Other 6.25% (n = 1). CPN was performed 3 times or 12% of procedures. Of the 17 samples taken, 65 % (n = 11) were malignant while 35% (n = 6) were benign. The average size of target biopsied was 32.8 mm × 25.2 mm (standard deviation 14.18 × 12.9) with a range of 11-73 mm and 8-65 mm. No immediate or long-term complications occurred. CONCLUSION: An ultra-slim echoendoscope is very useful and may be better tolerated in individuals with low body weight, altered anatomy and stenosis in the GI track and in patients with lung cancer. Further modifications are warranted to allow more therapeutic interventions with this important addition to the endosonographer daily armamentarium.

A prospective trial of CONfocal endomicroscopy in CYSTic lesions of the pancreas: CONCYST-01.

Background and study aims Pancreatic cystic lesions (PCL) are common. While some harbor malignant potential, accurate preoperative diagnosis remains challenging. Needle-based confocal laser endomicroscopy (nCLE) via a 19G FNA needle enables real-time imaging of the cyst wall. This study evaluated the safety and utility of nCLE in patients with an indeterminate PCL undergoing EUS-FNA. Patients and methods The CONCYST study prospectively recruited patients with indeterminate PCL attending three hepatopancreaticobiliary (HPB) referral centers in the UK, with indeterminate PCL, who required EUS-FNA between July 2014 and October 2016. Following the procedure, all patients were followed up in telephone clinic for at least 12 months. Ethical approval for the study was granted by the National Research Ethics Service (14/LO/0040). Results Sixty-seven patient were recruited, 11 excluded and 56 included in the final analysis: 35 male, 21 female; median age 68 (range 28 – 80). Recognizable confocal images were obtained in 48 of 56 cases. Median nCLE scanning time was 5 minutes and did not exceed 10 minutes in any case. EUS-nCLE findings correlated with final diagnosis (based on imaging, cytology and multidisciplinary team review) in 43/56 (77 %) of cases, compared with 37/56 (66 %) for cytology alone ( P = 0.12). One patient experienced mild pruritus following the procedure and another developed an infected pseudocyst, which resolved with antibiotics. Conclusions EUS-nCLE under conscious sedation in the day case setting is safe and provides additional information to standard EUS-FNA for diagnosing indeterminate PCL.

Comparison of endoscopic ultrasound-guided tissue acquisition using 22 G versus 20 G procore needles in solid lesions: a pilot study

EnBackground and aimEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) allows tissue acquisition from solid lesions. The endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle was developed to improve diagnostic yield by acquisition of histological core. The impact of the needle type (FNA or FNB) on the diagnostic yield and the technical success needs to be further studied. Therefore, the aim of our study was to compare the diagnostic accuracy and technical success of the 22-G FNA needle with the 20-G procore FNB needle in solid lesions.Patients and methodsThe study was designed as a pilot study conducted on cases with solid mediastinal, pancreatic, and intra-abdominal lesions, and the patients involved were then randomized for tissue sampling using either the standard 22-G FNA needle or the new 20-G procore FNB needle.ResultsIn this six-month study, 50 patients including 29 male individuals and 21 female individuals, with a mean age of 57.1±12.3 years (range: 15–80 years) were enrolled. No significant difference was detected between FNA 22 G and FNB 20 G as regards the diagnostic accuracy or the technical success rates. However, there was a significant difference in the number of passes needed to reach diagnosis. The success rate of first pass for FNA 22 G and FNB 20 G was 69 and 92.5%, respectively (P=0.014, 95%CI).ConclusionEUS-guided FNA and FNB have comparable diagnostic accuracy for solid lesions. The 20-G FNB needles are easy to handle in anatomically challenging locations and required fewer needle passes to reach diagnosis.

Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: A meta-analysis.

Robust data in favor of clear superiority of 22G fine-needle biopsy (FNB) over 22G FNA for an echoendoscopic-guided sampling of pancreatic masses are lacking. The objective of this study is to compare the diagnostic outcomes and sample adequacy of these two needles. Computerized bibliographic search on the main databases was performed and restricted to only randomized controlled trials. Summary estimates were expressed regarding risk ratio (RR) and 95% confidence interval. A total of 11 trials with 833 patients were analyzed. The two needles resulted comparable in terms of diagnostic accuracy (RR 1.02, 0.97–1.08; P = 0.46), sample adequacy (RR 1.01, 0.96–1.06; P = 0.61), and histological core procurement (RR 1.01, 0.89–1.15; P = 0.86). Pooled sensitivity in the diagnosis of pancreatic cancer was 93.1% (87.9%–98.4%) and 90.4% (86.3%–94.5%) with biopsy and aspirate, respectively, whereas specificity for detecting pancreatic cancer was 100% with both needles. Analysis of the number of needle passes showed a nonsignificantly positive trend in favor of FNB (mean difference: −0.32, −0.66–0.02; P = 0.07). Our meta-analysis stands for a nonsuperiority of 22G FNB over 22G FNA; hence, no definitive recommendations on the use of a particular device can be made.

Non-Malignant Gastric Outlet Obstruction: Therapy With Endoscopic Ultrasound Guided Gastrojejunonostomy

We describe here an 82 year-old male with past medical history of coronary artery disease, sick sinus syndrome s/p permanent pacemaker insertion who presents with a three day history of nausea and vomiting. A CT scan was obtained in the emergency department that showed a markedly distended abdomen. Although no discrete mass was seen, findings were concerning for a gastric outlet obstruction (GOO) (Figure 1). The patient was made NPO and a nasogastric tube was placed for decompression. Of note, the patient was hospitalized at an outside facility 1 month prior due to a severe gastro-intestinal hemorrhage. An endoscopy performed at that time revealed that a ulcerated mucosa encompassing two-thirds of the second portion of the duodenum.2130_A Figure 1 No Caption available.A repeat EGD was performed at our facility revealing a benign appearing high grade stricture in the duodenal bulb at the base of a healing ulcer. Stone-like accretions were found in the pylorus and duodenal bulb which were noted to intermittently occlude the stricture (Figure 2). Biopsies were taken which were negative for malignancy.2130_B Figure 2 No Caption available.The decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ). Sonographic examination of the stricture did not reveal an obvious mass. A stone-extraction balloon over a wire was advanced thorough the duodenal stricture into the jejunum. Sterile water was used to dilate the jejunal limb. The linear echoendoscope advanced to the stomach and the jejunal limb was identified. A 19G FNA needle was used to puncture into the jejunum and a second wire was advanced into this limb. Under endoscopic, fluoroscopic and sonographic guidance a 15mm lumen-apposing metal stent (LAMS) was successfully deployed, creating a gastrojejunostomy (Figure 3).2130_C Figure 3 No Caption available.Post-procedure day one patient tolerated a soft diet and was discharged after a 48 hour observation periord. At outpatient follow-up, six weeks after presentation, the patient has done well without significant complications. EUS-GJ are not common-place, however their utility in the treatment of malignant as well as benign gastric outlet obstruction has been demonstrated in international prospective trials. Here we demonstrate that EUS-GJ can be a reliable intervention in patients with GOO. In the future we hope for a comparison study between LAMS, enteral stents and surgical gastrojejunostomies.

Gastric Access Temporary for Endoscopy (GATE): An Algorithmic Approach Towards LAMSAssisted Temporary Reversal of Gastric Bypass Anatomy to Perform Foregut Procedures Presidential Poster Award

Introduction: Performing endoscopic foregut procedures in patients with Roux-en-Y gastric bypass anatomy is often technically difficult. Historical options include device-assisted enteroscopy and surgically-assisted transgastric access. EUS-Directed trans-Gastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has been described for ERCP in this population; however, there is concern for possible gastric fistula following LAMS removal. We describe an algorithmic approach(Gastric Access Temporary for Endoscopy (GATE)) for LAMS-assisted temporary reversal of bypass anatomy that minimizes gastric fistula formation and facilitates a variety of endoscopic procedures. Methods: Study design: Retrospective analysis of prospectively collected data at a single academic center. GATE access/removal: A linear or forward viewing therapeutic EUS scope was used. Based on anatomy, jejunum-to-gastric remnant or gastro-gastric access was created [Figure 1 and 2].The remnant stomach was accessed using a 19-G FNA needle and filled with saline/contrast. A 0.035” guidewire was advanced into the remnant stomach and the FNA needle removed. Using cautery enhanced delivery, a 15 mm x 10 mm LAMS stent was placed and dilated to a minimum of 15 mm. The indicated foregut procedure (ERCP, EUS, ESD, suturing) was then performed via the LAMS. LAMS removal using forceps occurred at the end of the procedure or at a later date [Figure 2], and a double pigtail stent (5 Fr or 10 Fr) was deployed in its place [Figure 3]. Access closure was confirmed by endoscopy and fluoroscopy.768_A Figure 1. Visualization of possible access sites for GATE in RYGB anatomy. (A) Endoscopic route of duodenoscope without LAMS access to engage the ampulla under RYGB anatomy. (B), (C), and (D) illustrate the path of the duodenoscope when a LAMS is placed under EUS guidance, providing access to the remnant stomach from either the gastric pouch, blind limb, or Roux limb respectively.768_B Figure 2. Algorithmic Approach for Patients Undergoing GATE768_C Figure 3. Endoscopic Images of GATE access, removal, and confirmation of fistula closure. (A) Lumen apposing metal stent deployed at fistula tract with guidewire still in place, (B) plastic double pigtail stent in position at fistula tract present in the gastric pouch (circled in red), several weeks after LAMS exchange, and (C) same location of the prior fistula tract having completely closed after stent removal.Results: 10 patients received the GATE procedure from May 2017 to June 2018. GATE access and removal were successful in 10/10 (100%) of patients. Foregut procedure included ERCP in 7, EUS/ERCP in 2, and ESD/suturing in 1. Gastric and jejunal access points for LAMS deployment were 30 and 70% respectively. Total procedure time per patient, including LAMS deployment, indicated procedure, and all follow-up, averaged 3.68±0.88 hours. 2 patients (20%) had complications that completely resolved after conservative management. For patients with complete follow-up (n=7), fistula closure rate was 100%. Conclusion: GATE allowed a variety of foregut endoscopic procedures in gastric bypass anatomy with successful closure in all patients. LAMS exchange to a smaller double pigtail stent appears safe and may minimize risk of residual fistula. This procedure is technically challenging and currently should be performed at centers with LAMS experience.

Love It or GIST It: Looking Beyond the GIST

A 40-year-old Caucasian woman with no significant history was referred for an EUS. She initially presented with acute epigastric pain radiating into the back that improved after changing her diet. EGD showed esophagitis and she was treated for H.pylori. A CT was obtained that revealed an abdominal mass. A CT with pancreatic protocol further defined this mass to have multiple cystic components but appeared to be exophytic to the pancreas yet defined it as possibly pancreatic cystic neoplasm. Another CT suggested that the heterogeneous mass that is located between the stomach and pancreas likely represents a gastrointestinal Stromal tumor. An EUS with a linear echoendoscope placed in the stomach easily identified the mass in the retroperitoneum as having both solid and cystic components. It could be seen abutting the pancreas but was clearly not arising from the pancreatic parenchyma or from the stomach. Under Doppler guidance, two passes were made with 22G FNA needle into the solid component of the lesion and then 4cc of blood aspirate obtained from the cystic region. The patient tolerated the procedure well with stable blood pressure throughout and during careful monitoring in the recovery area. She received three days of antibiotics post procedure. Cytology of the solid component was positive for an epithelial neoplasm. Immunohistochemical analysis showed tumor cells positive for AE1/AE3, CK 7, chromogranin, CD 56, and synaptophysin and negative for S100. With this in mind, the differential diagnosis was narrowed to a paraganglioma. Total 24-hour urine metanephrines were 196 (range 182-739), total 24-hour urine nor-metanephrine was 133 (range 88-649). A paraganglioma is a pheochromocytoma that arises outside of the adrenal medulla. It is a rare neoplasm with an incidence of 2-8 cases per million people per year. Functional paragangliomas may present with fluctuating hypertension, headache, palpitations and sweating: symptoms consistent with active secretion of catecholamines. Diagnostic dilemmas occur at the time of EUS with a paraganglioma as approximately only 10-14% of patients with a paraganglioma are asymptomatic, that may have precipitating symptoms, such as severe hypertension after FNA. Our patient, fortunately, did not experience any symptoms of catecholamine release and continues to do well after definitive laparoscopic resection.2167_A Figure 1. Immunohistochemical analysis showing tumor cells positive for chromogranin, medium power. EUS-FNA sample.2167_B Figure 2. Coronal view of Computed tomography image revealing a 2.2 x 4.7 x 4.6 cm heterogeneous appearing soft tissue mass between the stomach and pancreas2167_C Figure 3. sharply circumscribed global mass measuring 6 x 4.5 x 3.2cm and weighing 15 grams. The mass had an outer surface that has a dark-brown to black capsule, inked black. Serial sections revealed a variegated appearance ranging from a cystic (2.5 x 2.0 x 1.8cm) to deep-red, beefy with pale-tan white, fleshy areas. It appeared to be confined to the capsule without involvement of the outer surface.

1037 SUPERIORITY OF EUS-GUIDED RFA OVER EUS-GUIDED CPN FOR PALLIATION OF PAIN IN PANCREATIC CANCER IN A RANDOMIZED TRIAL

Although frequently performed, the efficacy of celiac plexus neurolysis (EUS-CPN) for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment modality for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer. Patients with abdominal pain due to locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n=14) or EUS-RFA (n=12). EUS-RFA was performed using a 1mm monopolar (Habib EndoHPB) probe passed via a 19G FNA needle and by targeting the area of celiac plexus or visualized ganglia. The primary endpoint was quality of life (QOL) as measured by the European Organization for Research and Treatment of Cancer (EORTC) core cancer (QLQ-C30) and pancreatic cancer-specific (QLQ-PAN26) questionnaires that were administered pre-treatment and at 2 and 4-weeks post-treatment. The core cancer (QLQ-C30) assessment revealed less pain (51.9 vs. 64.4, P=0.032) for EUS-RFA over EUS-CPN cohort. Likewise, when compared to EUS-CPN, the pancreatic cancer specific (QLQ-PAN26) questionnaire revealed less pain (49 vs. 57, P<0.001), fewer digestive symptoms (39.1 vs. 53.5, P=0.031), less alteration in bowel habits (16.9 vs. 24.8, P=0.029), less indigestion (20.6 vs. 51, P<0.001), less fear of future health (56.8 vs. 69.3, P=0.001) and better ability to plan for future (50.1 vs. 68.5, P=0.003) for the EUS-RFA cohort. Compared to EUS-CPN, EUS-guided RFA provided more pain relief and improved quality of life.

EUS-FNA using 22G nitinol or ProCore needles without on-site cytopathology.

Objectives:The project is aimed to compare the tissue sampling rate and the diagnostic accuracy rate of EUS-FNA using 22G nitinol and reverse bevel-tipped needles.Subjects and Methods:This was a prospective, randomized, crossover study in a tertiary academic hospital. All consecutive adult patients undergoing EUS-guided FNA for lesions > 2 cm were recruited. Patients fulfilling the inclusion and exclusion criteria underwent EUS-guided FNA using both needles in sequence. They were randomized on a 1:1 basis to determine whether EUS-FNA would be performed first using the 22G reverse bevel-tipped (ProCore) needle followed by the nitinol needle or vice versa. The patients and the pathologists were blinded to the type of needle used.Results:Forty patients with suspected malignant neoplasms were recruited to the study. No significant differences were found in the diagnostic yield (76.9% vs. 84.6%, P = 0.389), accuracy (71.8% vs. 84.6%, P = 0.170), sensitivity (77.8% vs. 86.1%, P = 0.358), specificity (100% vs. 100%, P = 1), positive predictive value (100% vs. 100%, P = 1), and negative predictive value (20.0% vs. 28.6%, P = 1). The percentage of obtained tissue for histological assessment was also similar (41.0% vs. 46.2%, P = 0.648). In terms of the quantity of tissue obtained with the needles, a larger proportion of patients in the nitinol group obtained more tissue for assessment (P = 0.003).Conclusion:The tissue-sampling rate and the diagnostic accuracy of the new 22G ProCore needle were comparable to the conventional 22G FNA needle in the absence of an on-site cytopathologist.

Comparison of 22-gauge standard fine needle versus core biopsy needle for endoscopic ultrasound-guided sampling of suspected pancreatic cancer: a randomized crossover trial

Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is effective for tissue diagnosis of pancreatic mass. To improve diagnostic yield and drawbacks, 22-gauge (G) core biopsy (FNB) needle has been developed. This study aims to compare 22G FNA and FNB needles for EUS-guided sampling of suspected pancreatic cancer.Methods: This is a randomized controlled crossover trial. A total of 60 patients with suspected unresectable pancreatic cancer referred for EUS-guided sampling were randomly assigned to two groups. Both groups had 22G FNA and FNB needles performed in a randomized order. The primary endpoint was the cytological, histological and overall diagnostic accuracy of pancreatic cancer.Results: FNA and FNB needles reported similar level of diagnostic accuracy (FNA needle 95% vs. FNB needle 93.3%; p = .564), and it was not statistically different. However, cytological cellularity was significantly higher in the FNB needles compared to FNA needles (odds ratio 2.75, 95% confidence interval (CI)). There were no procedure-related complications in both needles.Conclusions: The diagnostic accuracy of EUS-guided sampling for pancreatic cancer using 22G FNA is comparable to FNB needles. The cytological quality of specimen is better in the FNB needle.

Endoscopic Gastrojejunostomy: A Novel Approach to Roux Obstruction Following Roux-en-Y Hepaticojejunostomy: 2017 Presidential Poster Award

Roux-en-Y hepaticojejunostomy (RYHJ) is a procedure generating a direct connection between the hepatic bile ducts and the jejunum. Major indications include biliary strictures and iatrogenic injuries while studies have also indicated a role in biliary cancer. We present a novel endoscopic treatment of a Roux limb obstruction following RYHJ for a cholangiocarcinoma. A 75-year-old female with a history significant for cholangiocarcinoma involving the extra-hepatic biliary tract underwent a RYHJ following complete biliary duct resection. Two months following surgery, she presented with abdominal pain with labs suggestive of cholestatic disease. Abdominal CT revealed a very large distended Roux limb (Figure 1), thus a percutaneous biliary drain (PBD) was subsequently placed. One month later, trial of internal biliary drainage was unsuccessful. Cholangiogram noted a patent PBD and hepaticojejunal anastomosis, however again indicated obstruction. To avoid open repair, endoscopic therapy was performed. Following a normal EGD, EUS revealed a dilated Roux limb abutting the gastric antrum (Figure 2). This was confirmed by visualization of both guide wire advancement and contrast injection into the PBD. Initial fistulizing was attempted using a Hot AXIOSTM stent system; however, device deployment failed. Under EUS, a 19g FNA needle was introduced into the limb with advancement of a guide wire. The FNA needle was exchanged for needle-knife instrumentation and multiple cutting passes were performed. The fistula was dilated with an 8mm balloon and two double-pigtail stents were deployed with excellent biliary return (Figure 3). Directional flow was verified under fluoroscopy with contrast injection through her PBD. Lastly, a cholangioscopy performed through the PBD, further confirmed the pigtail catheter placement within the Roux limb. Follow-up cholangiogram 2 weeks later noted patent stents, and the PBD was removed. Multiple EUS-guided techniques have been described in the literature for biliary obstructions. In 2014, a “modified RYHJ” reported fixing the distal Roux limb to the anterior gastric wall for secured endoscopic access should the need arise. However, this has not been universally implemented. Thus, with the recent paradigm shift to minimally invasive endoscopic interventions in an effort to circumvent invasive surgical repair, we have described a safe alternative for the treatment of Roux limb obstructions following a “traditional” RHYJ.Figure: CT abdomen and pelvis noting a distended Roux limb adjacent to the liver.Figure: EUS noting a distended Roux limb abutting the gastric antrum.Figure: Direct visualization with EGD of two double-pigtail stents within the gastric antrum.

Diagnostic Yield of Micro Forceps Biopsies during Endoscopic Ultrasound Evaluation of Pancreatic Cystic Lesions

Introduction: Evaluation of pancreatic cystic lesions (PCLs) can be challenging and requires a combination of radiologic imaging, morphologic characteristics on endoscopic ultrasound (EUS), cyst fluid cytology, and cyst fluid analysis. Through-the-needle micro forceps (Moray micro forceps, US Endoscopy, Mentor, OH) are a recent addition to EUS armamentarium. These forceps allow tissue sampling from PCLs and may improve diagnostic yield. To date, scant data exists on the use of micro forceps biopsy for these lesions. The main aim of this study was to assess diagnostic yield and safety of EUS-guided micro forceps biopsy for PCLs. Methods: Our electronic endoscopy database was queried to identify patients who underwent EUS-FNA of PCLs and biopsies with the micro forceps, during the same procedure. Cysts were identified on EUS and punctured using 19-G FNA needle. All patients received peri-procedural antibiotics. Cyst fluid was collected for cytologic analysis, CEA and amylase levels, and wall of the cyst was biopsied using micro forceps through the 19-G needle. Adverse events were recorded per published ASGE criteria. Results: Twenty patients (mean age 64.2 years [range 34 -87]; 8/20 male [40%]) underwent EUS-FNA and micro-forceps biopsy of PCLs from 02/2016 to 05/2017. The mean cyst size was 34.4 mm (range 13 -70 mm), with 10 cysts in the pancreatic head/uncinate and 10 in the body/tail region. Micro forceps biopsies were technically successful in all cases, and provided a diagnosis of neoplasia in 11 cases (55%), benign tissue in 8 cases (40%) and insufficient quantity in 1 case. In 4 patients (20%), micro forceps biopsy results drastically changed patient management, providing diagnoses (1 Neuroendocrine tumor, 1 mucinous cystic neoplasm, and 2 IPMNs) otherwise not suggested by cytology or cyst fluid analysis. However, cytology provided a diagnosis of mucinous neoplasm in 3 cases not detected by micro forceps biopsies. No adverse events were noted. Conclusion: Micro forceps biopsies were associated with high yield and excellent safety profile. Biopsies provided a diagnosis of neoplasia not detected by cytology in a significant number of patients but also did not identify mucinous neoplasms in a few cases as suggested by cyst fluid cytology. Hence micro forceps biopsies may be a useful adjunctive tool for EUS guided assessment of PCLs, complementing existing EUS-FNA sampling protocols.