Brush Cytology Research Articles

Lochial and endometrial cytological changes during the first 10 days post-partum with special reference to the nature of foaling and puerperium in equine

During the puerperium, pregnancy-associated changes of the uterus need to be reversed. The duration of this process is of importance in terms of breeding efficiency and thus monitoring and treatment of the disturbed puerperium are essential. Aim of this investigation was to identify changes over time in the cellular composition of samples from endometrium and lochia in 120 mares with different obstetrical and puerperal history. In regular examinations up to 10 days post-partum the uterine involution was assessed by transrectal palpation and ultrasound. The vagina and cervix were examined using a speculum. Mares were classified as having an undisturbed or disturbed puerperium based on history and clinical findings. Uterine cytology samples were obtained with a cytology brush and lochia were obtained by manual withdrawal. Smears were done by rolling the brush or the swab on slides. They were stained using Hemacolor®-staining. In total, 238 cytology and 150 lochia smears were examined. Endometrial cells, neutrophils, and erythrocytes were distinguished by light-microscopy. Changes in the neutrophil granulocyte count in cytology and lochia smears were determined. The correlation between the number of neutrophils in cytology and lochia smears was not significant (p = 0.22). There was a significant influence of the puerperium on the percentage of neutrophils in the cytology samples (p = 0.001) but not in the lochia smears (p = 0.83). A significant decline of erythrocytes was detected in cytologies (p < 0.0001) and lochia smears (p = 0.12) of mares after eutocia but not after dystocia. Retention of fetal membranes (p = 0.0004) and time (p = 0.0034) had a significant influence on the percentage of neutrophils in the endometrial cytology. The type of birth (p = 0.0018) and the time (p = 0.0011) significantly affected the decrease in neutrophils in the cytology samples but not in the lochia smears. The influence of time was also found for the decrease of erythrocytes in cytology (p < 0.0001) and lochia (p = 0.0082) samples. A constant decline in neutrophils (p < 0.001) was found in the cytologies of mares with an undisturbed puerperium. Therefore, endometrial cytology seems to be more appropriate than lochia assessment for the evaluation of puerperal development in mares.

The Role of Peroral Cholangioscopy in Evaluating Indeterminate Biliary Strictures.

Biliary strictures are considered indeterminate when the initial radiologic evaluation and endoscopic retrograde cholangiopancreatography with brush cytology and/or forceps biopsy do not reveal diagnostic findings. Evaluation of these strictures is challenging and often requires a multidisciplinary approach and multiple procedures. Peroral cholangioscopy allows direct visualization of these lesions and targeted tissue acquisition using miniature biopsy forceps. In the past decade, there have been significant improvements in the field of cholangioscopy. These advances have allowed higher-quality image acquisition, easy setup, operation by a single operator, easy maneuverability, and excellent targeted tissue sampling performance. However, the interpretation of cholangioscopic visual findings remains challenging. In this review, we discuss the role of peroral cholangioscopy in the evaluation of indeterminate biliary strictures.

AGA Clinical Practice Update on Surveillance for Hepatobiliary Cancers in Patients With Primary Sclerosing Cholangitis: Expert Review

The purpose of this clinical practice update is to define key principles in the surveillance of hepatobiliary cancers including cholangiocarcinoma, gallbladder adenocarcinoma, and hepatocellular carcinoma in patients with primary sclerosing cholangitis (PSC). The recommendations outlined in this expert review are based on available published evidence including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Surveillance for cholangiocarcinoma and gallbladder cancer should be considered in all adult patients with PSC regardless of disease stage, especially in the first year after diagnosis and in patients with ulcerative colitis and those diagnosed at an older age. BEST PRACTICE ADVICE 2: Surveillance for cholangiocarcinoma and gallbladder cancer should include imaging by ultrasound, computed tomography, or magnetic resonance imaging, with or without serum carbohydrate antigen 19-9, every 6 to 12 months BEST PRACTICE ADVICE 3: Endoscopic retrograde cholangiopancreatography with brush cytology should not be used routinely for surveillance of cholangiocarcinomas in PSC. BEST PRACTICE ADVICE 4: Cholangiocarcinomas should be investigated by endoscopic retrograde cholangiopancreatography with brush cytology with or without fluorescence in situ hybridization analysis and/or cholangioscopy in PSC patients with worsening clinical symptoms, worsening cholestasis, or a dominant stricture. BEST PRACTICE ADVICE 5: Fine-needle aspiration of perihilar biliary strictures should be used with caution in PSC patients considered to be liver transplant candidates because of concerns for tumor seeding if the lesion is a cholangiocarcinoma. BEST PRACTICE ADVICE 6: Surveillance for cholangiocarcinoma should not be performed in PSC patients with small-duct PSCs or those younger than age20. BEST PRACTICE ADVICE 7: The decision to perform a cholecystectomy in PSC patients with a gallbladder polyp should be based on the size and growth of the polyp, as well as the clinical status of the patient, with the knowledge of the increased risk of gallbladder cancer in polyps greater than 8 mm. BEST PRACTICE ADVICE 8: Surveillance for hepatocellular carcinoma in PSC patients with cirrhosis should include ultrasound, computed tomography, or magnetic resonance imaging, with or without α-fetoprotein every 6 months.

CDK4, CDK6, cyclin D1 and Notch1 immunocytochemical expression of oral brush liquid-based cytology for the diagnosis of oral leukoplakia and oral cancer.

This study aimed to investigate the feasibility of using oral liquid-based brush cytology (OLBC) coupled with immunocytochemistry as a minimally invasive approach to stratify the cancer risk in patients with oral leukoplakia. Fifty-five patients diagnosed with either oral leukoplakia (OLK) or oral squamous cell carcinoma (OSCC) were recruited. All patients underwent oral brush biopsy followed by surgical biopsy. 275 liquid-based cytology preparations were made. Pap-stained OLBC slides were assessed using the modified 2014 Bethesda Cytology system. The expression of CDK4, CDK6, cyclin D1, and Notch 1 was immunocytochemically analysed and compared against the histopathological diagnosis. A combined index score of OLBC grading and protein expression was calculated. A significant association was found between the definitive histopathological diagnosis and the cytological interpretation (P=0.0005). The index scores of CDK4, CDK6, and cyclin D1 were significantly associated with the development of disease from non-dysplastic epithelium to OSCC. No significant association was observed between the Notch 1 index score and disease stage. The diagnostic accuracy of OLBC showed the highest values of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy: 84.6%, 70.4%, 73.3%, 82.6%, and 78.8%, respectively, compared with the cumulative protein index, CDK4/6 index, and the combined OLBC grading and CDK4/6 index. This study has also demonstrated the efficacy of the use of OLBC in the detection of OED and OSCC, and showed that the use of CDK4, CDK6, cyclin D1, and Notch 1 immunocytochemistry failed to improve the diagnostic accuracy of OLBC suggesting they are not useful in the early detection of OSCC.

Evidence of genotoxicity and cytotoxicity of X-rays in the oral mucosa epithelium of adults subjected to cone beam computed tomography.

Evidence of genotoxicity and cytotoxicity of X-rays in the oral mucosa epithelium of adults subjected to cone beam computed tomography.

Mixed adenoendocrine carcinoma in the extrahepatic biliary tract: A case report and literature review.

Neuroendocrine neoplasm (NEN) comprises a group of tumors that exhibit neuroendocrine phenotypes. NEN is subclassified into neuroendocrine tumor (NET), neuroendocrine carcinoma (NEC) and mixed adenoendocrine carcinoma (MANEC), based on histopathological parameters. NEN in the extrahepatic biliary tract (EHBT) is uncommon. Little is known about its clinicopathological features and prognostic indicators. The present study presented a case of MANEC in the distal common bile duct (CBD) and reviewed previous cases of NENs in the EHBT to characterize the clinical settings of this disease entity and to identify influencing factors of survival outcomes. A 64-year-old Chinese woman presented with abdominal pain and jaundice. Imaging studies demonstrated malignant stenosis in the distal CBD. Bile duct brush cytology revealed small clusters of atypical cells. Following an initial diagnosis of distal cholangiocarcinoma (CCA), the patient underwent pancreaticoduodenectomy. Histological analysis combined with immunohistochemical investigation of the resected specimen revealed a collision tumor that was composed of poorly differentiated adenocarcinoma and NEC. Each histological component accounted for >30% of the tumor. The definitive diagnosis was a MANEC in the distal CBD. Multiple intrahepatic and pulmonary metastases were observed postoperatively over 8 months. The patient succumbed to the disease 12 months after surgery. In conclusion, NEN occurs infrequently in the EHBT, with NET being the predominant type. NEN in the EHBT is extremely challenging to diagnose preoperatively due to its tendency to mimic CCA. Patients with NEN in the EHBT exhibited extremely distinct oncology outcomes according to pathological types. Additionally, old age (>60 years) and the presence of tumor recurrence were associated with decreased survival of patients with NEN.

Metastasis of ovarian cancer to the bile duct: a case report

BackgroundOvarian cancer typically spreads along the peritoneum or metastasizes through the blood or lymphatic stream. The bile duct is an extremely rare site of ovarian cancer-associated metastases.Case presentationA 55-year-old female underwent surgery for advanced left ovarian cancer 2 years ago. She was diagnosed with ovarian serous adenocarcinoma with multiple peritoneal metastases. She received chemotherapy for the residual peritoneal metastases. She achieved a clinical complete response and was followed up with imaging examinations for 1 year. She then complained of dark urine, yellowish discoloration of the eyes, and weight loss. Computed tomography showed an approximately 10-mm solid tumor at the hepatic hilum. Simultaneously, multiple peritoneal metastases were detected in the abdominal and pelvic cavity. Intraductal ultrasonography suggested that the hepatic hilum tumor was located in the bile duct wall. Tumor biopsy and brush cytology of the bile duct indicated atypical cells suspicious for carcinoma. After percutaneous transhepatic portal embolization, she underwent right hepatectomy and extrahepatic bile duct resection for the hepato-hilar tumor. The histopathological features were dysplastic cells with hyperchromatic nuclei and no dysplastic cells in the native biliary epithelium. Immunohistochemical staining revealed that the tumor cells were positive for CK-7 and WT-1 and negative for CK-20 and ER. These results suggested that the tumor was a metastasis of the ovarian serous adenocarcinoma.ConclusionThis may be the first case of ovarian cancer metastasis to the bile duct. While it is extremely rare, ovarian cancer may metastasize to the hepatic duct, mimicking hilar cholangiocarcinoma.

Sa1465 SINGLE OPERATOR CHOLANGIOSCOPY- DIRECTED BIOPSIES IMPROVES DIAGNOSTIC YIELD FOR CHOLANGIOCARCINOMA AND IS SAFE IN PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS

Single operator cholangioscopy (SOC) has demonstrated to be a useful tool in the evaluation of indeterminate biliary strictures. However much of the incremental benefit has been ascribed to the visual interpretation of cholangioscopy and not due to histologic yield from SOC-directed biopsies. Furthermore, SOC has been suggested to be a cost-effective strategy for evaluation of indeterminate biliary strictures in patients with primary sclerosing cholangitis (PSC), but data comparing the addition of fluorescent in situ hybridization (FISH) to SOC in this population is lacking. The purpose of this study is to assess the performance characteristics of histopathology from SOC-directed biopsies compared to traditional sampling techniques [Routine brush cytology (Bc), fluorescent in situ hybridization (FISH), and transpapillary fluoroscopic-guided cold biopsy (Bx)] for indeterminate biliary strictures and to compare diagnostic yield and safety of the procedure in patients with and without PSC.

The value of DNA image cytometry combined with brush routine cytology in diagnosing indeterminate biliary strictures: A large sample size retrospective study.

Brush cytology is widely applied to diagnosis indeterminate biliary stricture but suffer from low sensitivity. Changes in DNA content are a character of malignant cell and can be detected by DNA image cytometry (DNA-ICM). The study aimed to estimate the value of routine cytology (RC), DNA-ICM, and their combination in diagnosing indeterminate biliary strictures. A total of 362 patients who underwent both RC and DNA-ICM tests were analysed. Their results were retrospectively applied to final diagnoses. Diagnostic values were compared among RC, DNA-ICM, and their combination based on the location of strictures. The DNA-ICM and combination of two methods had higher diagnostic accuracy than RC in all strictures (63.3% vs 42.3%, P<0.001, 64.36% vs 42.3%, P<0.001) and in distal strictures (65.36% vs 42.81%, P<0.001, 66.01% vs 42.81%, P<0.001). But in proximal strictures, DNA-ICM showed no superior (51.8% vs 42.81%, P=0.184). Combination of two methods was not fully significant superior to RC in proximal strictures (55.36% vs 39.29%, P=0.089). After classification of "suspicious for malignancy" as positive for malignancy, the diagnostic accuracy of DNA-ICM was still higher than that of RC in all strictures (63.3% vs 51.9%, P=0.002) and in distal strictures (65.36% vs 52.29%, P=0.001). Combination of two methods was no superior to DNA-ICM alone (64.36% vs 63.3%, P=0.757). The utilization of DNA-ICM was more accurate in distal strictures than in proximal strictures (65.36% vs 51.8%, P=0.017). DNA-ICM is an objective and effective addition tool with RC, especially in distal strictures. The combination of DNA-ICM and RC showed no superior to DNA-ICM alone but could improve diagnostic accuracy to RC in proximal strictures although not fully significant.

Comparison of intraductal ultrasonography characteristics between cholangiocarcinoma and benign bile duct stricture

Objective To conclude the intraductal ultrasonography (IDUS) characteristics of cholangiocarcinoma and improve endoscopic diagnosis for cholangiocarcinoma by comparing manifestations of IDUS between cholangiocarcinoma and benign bile duct stricture. Methods A total of 52 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and IDUS with definite diagnosis of cholangiocarcinoma from January 2012 to January 2017 were included in this retrospective study, and 59 patients undergoing ERCP and IDUS during the same period with definite diagnosis of benign bile duct stricture were included as control. Clinical data, indices of laboratory tests, and manifestations of IDUS (including length of stricture, echo feature, thickness of bile duct, symmetry, and integrity of outer membrane of bile duct wall) were collected and compared between the two groups. Results The clinical manifestations and results of laboratory examination showed no significant differences between the two groups. Intraductal brushing cytology and forceps biopsy showed 28.9% and 40.0% malignant evidence respectively. IDUS showed thicker bile duct in the cholangiocarcinoma group (6.8±4.0 mm VS 4.1±2.3 mm, P<0.01). Proportion of hypoechoic and nonsymmetrical thickened bile duct was higher in the cholangiocarcinoma group (78.8% VS 44.1%, 92.3% VS 50.8%, respectively, all P<0.01). Outer membrane of bile duct destruction occurred in 8 cases (15.4%) in the cholangiocarcinoma group, whereas none was seen in the control group. Conclusion Hypoecho and nonsymmetrical thickness on IDUS may be indicators of cholangiocarcinoma, and destruction of bile duct outer membrane is highly suggestive of cholangiocarcinoma. Key words: Endosonography; Cholangiopancreatography, endoscopic retrograde; Bile duct neoplasms; Diagnosis

Analysis of microRNA expression in brush cytology specimens improves the diagnosis of pancreatobiliary cancer

Background/ObjectivesMalignant pancreatobiliary strictures are in many cases clinically indistinguishable and present a major problem to endoscopy specialists. Intraductal sampling procedures such as brush cytology are commonly used for diagnosis with a sensitivity that is low for a diagnostic test used in daily clinical practice. MicroRNA (miR) alterations detected in many cancers are disease-specific, which can be utilized in clinical applications. The aim of the present study was to analyze whether determination of miR expression levels in intraductal brush cytology specimens is a feasible approach to improve the diagnosis of pancreatobiliary cancer. MethodsBrush cytology specimens have been collected during endoscopic retrograde cholangio-pancreatography (ERCP) and analyzed by routine cytology and ancillary miR assays. Total RNA was extracted using the miRNeasy Mini Kit and the expression of miRs frequently dysregulated in pancreatobiliary cancer (miR-16, miR-21, miR-196a, miR-221) were analyzed by quantitative real-time PCR using RNU6B as internal control. ResultsRoutine cytology resulted in no false positive diagnoses, however, the combined sensitivity remained at 53.8%. Expression (ΔCt values) of miR-16 (p = 0.0039), miR-196a (p = 0.0003) and miR-221 (p = 0.0049) showed a clear statistical significance between malignant and benign pancreatobiliary specimens (n = 35). Malignancy could be detected combining routine cytology and the miR-196a single marker expression levels with a sensitivity of 84.6% (92.9% in biliary strictures) with no false positives. ConclusionsThe results offer the first direct demonstration that microRNAs are readily detectable in brush cytology specimens obtained during ERCP, and have the potential to help the cytological diagnosis of pancreatobiliary malignancy.

Impact of Brush Cytology Analysis for the Diagnosis of Esophageal Squamous Cell Carcinoma: The Quality of Liquid-Based Preparation of Cytological Slides

Objectives: The diagnostic performance of cytology in esophageal squamous cell carcinoma (ESCC) is meticulously described. Methods: Cytological and biopsy specimens were prospectively taken during esophagogastroduodenoscopy of 123 individuals in 2013 and 2014. Cytology samples were maintained in preservative fluid until processing and biopsies were formalin-fixed and paraffin-embedded. Results: Based on endoscopic biopsy results, 70 cases were positive for ESCC whilst 53 were negative for cancer. In addition, brush cytology showed high sensitivity and specificity (98.57 and 96.23%, respectively) in detecting the disease, and high accuracy (97.5%) comparable to that provided by histopathology which is the accepted gold standard. Conclusion: Brush cytology specimens preserved in liquid medium may be a good alternative for ESCC diagnosis.

Robotic pancreaticoduodenectomy with right hepatic artery resection

Background: Pancreaticoduodenectomy(PD) with en bloc hepatic arterial resection and reconstruction remains a controversial topic. Although use of robotic surgery has been increasing worldwide in patients requiring PD, hepatic arterial resection and reconstruction has not been previously described. This video depicts a first in utilizing the Davinci Si robotic system to perform a hepatic arterial vascular resection and anastomosis during PD. Methods: A 69 year-old female, presenting with obstructive jaundice, was diagnosed with a distal common bile duct cancer by ERCP and brushing cytology. CT scan imaging revealed the suspected tumor mass involving the proximal right hepatic artery. We performed a total robotic PD. Right hepatic artery (RHA) was involved by the tumor and segmental resection was performed to achieve en bloc resection. End-to-end anastomosis of RHA stump to distal part was carried out by using 5-0 proline suture robotically. The reconstruction, including the modified Blumgart fashion pancreatojejunostomy, choledochojejunostomy and gastrojejunostomy, were all accomplished intracorporeally using the robotic platform. Results: The total operative time was 499 minutes and estimated blood loss was 500ml. The patient was discharged on post-OP day 4 without complications. The final pathology was moderately differentiated pancreatic adenocarcinoma with extensive perineural invasion. Metastatic carcinoma was found in one of the ten lymph nodes. Conclusion: PD with hepatic artery resection and reconstruction can be performed safely using robotic surgery. Restoration of the resected hepatic artery may ensure the bilio-enteric anastomosis in the immediate and late post-operative course.

Supplemental progesterone induces temporal changes in luteal development and endometrial transcription in beef cattle

Long-acting injectable progesterone (iP4) supplementation during early diestrus is a strategy to increase conception rates in cow-calf beef operations. However, iP4 treatment causes early functional and structural regression of the corpus luteum (CL) in a proportion of iP4-treated animals, resulting in pregnancy loss. The hypothesis evaluated was that iP4 accelerates downregulation of sex-steroid receptors (PGR, ESR1, ESR2) during early to mid-diestrus and the upregulation of genes controlling PGF2α secretion (OXTR, PTGS2, AKR1B1) during late diestrus in the endometrium. Ovulations of cyclic, multiparous Nelore (Bos indicus) cows were synchronized, and cows were divided to receive placebo or 300 mg iP4 3 d postovulation (D3). Growth and vascularization of luteal tissue were evaluated by ultrasonography. Blood samples were collected from 3 d postovulation to 3 d after luteolysis, and P4 plasma concentrations were measured by radioimmunoassay. On days 3, 5, 7, 9, 11, 13, and 16 luminal endometrial samples were taken using a cytologic brush. Transcript abundance was measured by qPCR. Structural luteolysis occurred 3 d earlier in cows receiving iP4 compared to the control group. Analyzing only cows that received iP4, those that presented early luteolysis (ie, ≤ D16) showed a decrease in CL area and P4 concentration after D5, compared to the control group. Cows that presented early luteolysis showed a reduced abundance of transcripts on D5 for the ESR2 gene and a greater abundance of transcripts for OXTR and ESR1 on D16, compared to cows that did not present early luteolysis. The iP4-induced early luteolysis can be explained by two nonexclusive possibilities: the activation of uterine mechanisms that trigger early secretion of endometrial PGF pulses and the formation of a subfunctional CL that is prone to early regression.

Comparison of oral brush cytology and tissue biopsy in diagnosing oral lesions

Background: Oral cancer involves cancer of the lips, tongue, floor of mouth, cheeks, soft and hard palate and pharynx. It is the 6th most common cancer in Western world and second most common cancer in some parts of sub-continent . Oral cancers are often diagnosed at a late stage because oral lesions are usually considered benign and clinical examination is not accompanied by specific diagnostic tests. Brush biopsy is a simple and easy test to perform on suspicious lesions before they undergo biopsy.

Factors Associated with Malignant Biliary Strictures in Patients with Atypical or Suspicious Cells on Brush Cytology.

Background/AimsPathological diagnosis of biliary strictures with atypical or suspicious cells on endoscopic retrograde brush cytology and indeterminate strictures on imaging is challenging. The aim of this study was to identify markers for malignant strictures in such cases. MethodsWe retrospectively analyzed data collected from 146 consecutive patients with indeterminate biliary strictures on imaging who underwent endoscopic retrograde brush cytology from 2007 to 2013. Factors associated with malignant strictures in patients with atypical or suspicious cells on brush cytology were identified. ResultsAmong the 67 patients with a malignant disease (48 cholangiocarcinoma, 6 gallbladder cancer, 5 pancreatic cancer, 5 ampulla of Vater cancer, and 3 other types), 36 (53.7%) had atypical or suspicious cells on brush cytology. Among these, the factors that independently correlated with malignant strictures were stricture length (odds ratio [OR], 5.259; 95% confidence interval [CI], 1.802– 15.294) and elevated carbohydrate antigen 19-9 (CA19-9) (OR, 3.492; 95% CI, 1.242–9.815), carcinoembryonic antigen (CEA) (OR, 4.909; 95% CI, 1.694–14.224), alkaline phosphatase (ALP) (OR, 3.362; 95% CI, 1.207–9.361), and gamma-glutamyl transpeptidase (rGT) (OR, 4.318; 95% CI, 1.512–12.262). ConclusionsElevated levels of CA19-9, CEA, ALP, and rGT and stricture length are associated with malignant strictures in patients with indeterminate biliary strictures on imaging and atypical or suspicious cells on brush cytology.

Successful treatment of a benign biliary stricture with biodegradable metallic biliary stents

Background: A 19 year old boy from a UNHCR camp presented to our hospital with an insidious onset of painless jaundice without any constitutional symptoms. Biochemical and ultrasonograph confirmed obstructive jaundice. Tumor markers, brush cytology and infective parameters were all negative. We successfully treated the symptoms with a biodegradable metallic biliary stent. Methods: Pre-procedural MRCP confirmed presence of benign stricture at distal CBD with dilated biliary systems. We obtained consent to deploy a 10mm diameter x 40mm length Biodegradable Balloon Expandable Biliary Stent System (QualiMed Innovative Medizinprodukte GmbH, Germany) across the stricture via ERCP. It is a flexible, magnesium based stent pre-mounted on the balloon of an over-the-wire (OTW) stent delivery system. Results: Patient's symptom resolved. We performed a repeat MRCP and ERCP at 10 months. The stent has been fully degraded. There was no residual stricture and patient remained clinically and biochemically not jaundiced. The radial strength of the biodegradable biliary stent support and maintained the patency across the distal biliary stricture. It provided a controlled delayed degradation over time. The stent has a good fluoroscopic visibility with minimal foreshortening. Conclusion: The usability and mechanical properties of the Biodegradable Balloon Expandable Biliary Stent System are comparable to regular metalic stent systems, but with the advantage of fully degraded and leaving nothing behind.

Clinical impact of digital cholangioscopy in management of indeterminate biliary strictures and complex biliary stones: a single-center study.

Aims:Endoscopic management of indeterminate strictures and complex stones remains a challenge, for which the latest generation single-operator digital cholangioscope (SpyGlass DS) has shown promising results. We aimed to study the clinical impact of single-operator digital cholangioscope at our tertiary academic center.Methods:We retrospectively reviewed all digital cholangioscopies performed from June 2015 to May 2018. Patient characteristics, procedure characteristics, and post-procedural patient outcomes were recorded.Results:A total of 50 patients (26 men, average age 61.4 years) underwent 67 procedures. Indications were biliary stones (21/50, 42%), strictures and primary sclerosing cholangitis surveillance (22/50, 46%), and miscellaneous (7/50, 14%). The average procedure time was 82 ± 29 min (99.5 min for stones and 74.2 min for strictures). Stone clearance was achieved in 19/21 (90.47%) cases, with electrohydraulic lithotripsy employed in 16/21 and repeat cholangioscopy necessary in 9/21. Malignant strictures (10) were differentiated from benign (12) in all cases both in patients with primary sclerosing cholangitis (9) and in those without (13), based on visual cholangioscopic features (sensitivity and specificity 100%), single-operator digital cholangioscope–directed biopsies (sensitivity 60% and specificity 100%), and brush cytology (sensitivity 37.5% and specificity 100%). Complications included one post-sphincterotomy bleeding and one post-procedural cholangitis despite antibiotic prophylaxis, but no procedure-related mortality.Conclusion:Single-operator digital cholangioscope had a high success rate and a low rate of complications for management of indeterminate strictures and difficult biliary stones. Visual cholangioscopic features of biliary strictures had excellent diagnostic accuracy, and targeted biopsies outperformed brush cytology. Early implementation of cholangioscopy for select indications leads to successful patient outcomes and reduces diagnostic delays, cost, and risks of repeat endoscopic retrograde cholangiopancreatographies.

An unusual case of recurrent oral cancer in a young woman HPV-negative, non-smoker and non-drinker

An unusual case of recurrent oral cancer in a young woman HPV-negative, non-smoker and non-drinker

Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients.

ABSTRACTBackground and aimsHypoxemic patients undergoing fiber-optic bronchoscopy (FOB) are at risk of worsening of respiratory failure requiring mechanical ventilation due to FOB procedure itself and its complications. As patients with respiratory failure are frequently managed by non-invasive ventilation (NIV); feasibility of FOB through NIV mask has been evaluated in some studies to avoid intubation. We describe here our own case series.Materials and methodsClinical data of 28 FOB done through NIV mask in 27 intensive care unit (ICU) patients over 6 years period at our center was collected retrospectively and analysed.ResultsStudy comprises 27 (17 male; 52±21.6 years age) hypoxemic (PaO2 71.3±14.2, on NIV and oxygen supplementation) patients. All FOB were done at bedside, 15 of them were given sedation for the procedure. Twenty four patients had bronchoalveolar lavage (BAL); three underwent bronchial biopsies, four brush cytology and seven transbronchial biopsies. In 10 patients lung or lobar collapse was reversed. There was no significant change between pre and post bronchoscopy ABG parameters except for improved post FOB PaO2 (p = 0.0032) and SpO2 (p = 0.0046). One patient (3.57%) developed late pneumothorax and 3 patients (10.7%) had bleeding after biopsy. Prior to bronchoscopy 17 (16 BIPAP, 1 CPAP) patients were already on NIV. Two patients required mechanical ventilation 6 hours after FOB due to subsequent clinical deterioration but could be weaned off later. One patient died on third day after FOB from acute myocardial infarction.ConclusionHypoxemic patients in ICU can safely undergo bedside diagnostic and simple therapeutic bronchoscopy with NIV support while mostly avoiding intubation and with low complication rates.How to cite this articleSircar M, Jha OK, Chabbra GS, Bhattacharya S. Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients. Indian J Crit Care Med 2019;23(8):363-367.