Endoscopic Ultrasound-guided Research Articles

Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies.

Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5months. A total of 14 patients (5.9%) underwent re-intervention with the first 5months. This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.

National practice patterns in the use of endoscopic ultrasound biopsy for resectable Pancreatic Neuroendocrine Tumors: Insights into the role of DOTATATE PET/CT in diagnosis

IntroductionPancreatic neuroendocrine tumors (PNETs) are typically diagnosed using endoscopic ultrasound-guided (EUS) biopsy, which can be associated with complications. Since 2016, DOTATATE PET/CT has emerged as an effective tool to localize and stage PNETs. MethodsPatients with PNETs who underwent R0 resections were identified from the 2004–2019 National Cancer Database PUF. Joinpoint regression and multivariable logistic regression were used to analyze trends in the use of biopsy. ResultsOf 16,746 R0 resected PNET patients, 44 ​% underwent diagnostic biopsy. Joinpoint regression showed a significant increase in the use of biopsy from 2004 to 2019 (APC 1.80, p ​< ​0.001). A higher percentage of patients diagnosed after DOTATATE approval underwent biopsy compared to those diagnosed before (48 ​% vs. 42 ​%, p ​< ​0.001). Adjusted analysis showed diagnosis after 2016 was associated with increased odds of biopsy (OR ​= ​1.67, p ​< ​0.001). ConclusionsDespite technologic advancement with DOTATATE PET/CT, there has been a significant increase in the proportion of resectable PNETs undergoing preoperative biopsy.

Diagnostic Evaluation of Solid Pancreatic Lesions: Endoscopic Ultrasound-Guided Fine Needle Aspiration Versus Percutaneous Ultrasound-Guided Core Needle Biopsy.

The main objective of the present study is to compare the safety, technical success and diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) versus ultrasound-guided percutaneous core-needle biopsy (US-CNB) in patients with solid pancreatic lesions. This is a retrospective study that involved all patients with a solid pancreatic lesion who underwent EUS-FNA or US-CNB between November 2019 and February 2021. Of all patients, 69 (84.1%) had inoperable malignancy, whereas 13 (15.9%) had chronic pancreatitis. Resectability status was ascertained by computed tomography. All core needle biopsies were performed by the same interventional radiologist via ultrasound guidance with an 18-gauge semi-automatic tru-cut needle. All EUS-FNA procedures were performed by the same gastroenterologist with a 27-gauge EUS-FNA needle. Technical success is defined as if the region of interest is reached and specimen taken from the pancreatic lesion. Diagnostic yield is defined as the procurement of sufficient tissue for pathological examination. Overall, 52 patients (mean age 58.5 ± 9.8years) who underwent EUS-FNA and 30 patients (60.1 ± 12.1years) who underwent US-CNB were included. Solid lesions were most commonly (61.5% in EUS-FNA and 50.0% in US-CNB groups) located in pancreatic head in both groups. Mean size of the lesions was comparable in both groups as well. The technical success was 100% in both groups. In 12 (14.6%) patients, pathology results revealed inadequate sampling (11 × in the EUS-FNA and 1 × in the US-CNB group). The diagnostic yield was significantly higher in US-CNB group than in EUS-FNA group (96.7% vs. 78.8%, respectively, p = 0.048). Of 11 patients in the EUS-FNA with inadequate sampling, pancreatic lesions were located in the pancreatic head in 7 (63.6%). No major complications were observed in neither of the groups. As a minor complication, one case of slight abdominal pain was detected in the EUS-FNA group. Based on the results of the present study, both US-CNB and EUS-FNA appeared safe; however, diagnostic yield in the US-CNB group was significantly higher.

S2799 Disseminated Cryptococcosis Masquerading as Large Abdominal Mass Concerning for Pancreatic Malignancy in HIV-Positive Patient

Introduction: Gastrointestinal cryptococcus is a rare occurrence in HIV-positive patients. Symptoms may be nonspecific thus the differential for abdominal masses must remain broad. We report a patient with HIV who presented with abdominal pain and watery diarrhea, found to have a large abdominal mass on computed tomography initially thought to be lymphoma or a primary pancreatic tumor. He underwent endoscopic ultrasound-guided (EUS) biopsy of the mass which was consistent with a cryptococcoma. Case Description/Methods: A 55-year-old male presented with severe, diffuse abdominal pain for one week duration associated with profuse watery, non-bloody diarrhea and intermittent chills. Medical history included HIV for 30 years with poor compliance with antiretroviral regimen, recent pneumocystis pneumonia and previous cryptococcal meningitis. Physical exam revealed an ill appearing, cachectic male with abdominal tenderness. Labs revealed a white blood cell count of 18.5 K/uL (ref: 4.0-10.8 K/uL) with 84% neutrophils (ref: 40-75%), sodium of 132 mmol/L (ref: 135-146 mmol/L) and potassium 2.7 mmol/L (ref: 3.5-5.1 mmol/L). His viral load was 109,385 copies/mL (ref: neg copies/mL) and absolute CD4 count was 56 lymphocytes/uL (ref: 330-1520 lymphocytes/uL). Liver chemistries were unremarkable. Stool studies for regional pathogens, ova and parasites, and clostridium difficile were negative. A CT scan of the abdomen and pelvis revealed ill-defined cystic/necrotic upper abdominal lymphadenopathy with mass effect and possible invasion of the adjacent liver (Figure 1A). The pancreas and caudate lobe of the liver were inseparable from the mass which raised concern for primary pancreatic tumor or lymphoma. He underwent EUS-guided biopsy of the peripancreatic mass (Figure 1B) with pathology consistent with a cryptococcoma (Figure 1C, 1D). He was started on amphotericin B and transitioned to high dose fluconazole due to adverse effects. Repeat imaging revealed significant reduction of the mesenteric lymphadenopathy (Figure 1E). He was discharged in stable condition and remained on fluconazole indefinitely. Discussion: Cryptococcal infection remains the second most common cause of acquired immunodeficiency syndrome related mortality after tuberculosis. The most common sites of cryptococcal infection are the lungs, brain, eyes, or central nervous system; abdominal dissemination is rare. Biopsy via EUS can be useful in diagnosis of cryptococcoma. Early identification and treatment of cryptococcal infections can increase survival rates.Figure 1.: A) CT image showing ill-defined cystic/necrotic upper abdominal lymphadenopathy with mass effect and possible invasion of the adjacent liver B) Endoscopic ultrasound imaging showing peripancreatic mass C) Hematoxylin and Eosin cellblock at 40X magnification showing abundant neutrophils and necrotic debris D) Grocott’s Methenamine Silver stain showing fungal yeast with narrow base budding E) Significant reduction of the mesenteric lymphadenopathy after antifungal therapy initiation.

Efficacy of EUS-Guided Procedures in Patients with Walled-Off Pancreatic Necrosis: Results of Prospective Cohort Study

Introduction: Step-up application of surgical procedures is standard approach for the interventional treatment of acute necrotizing pancreatitis with transcutaneous ultrasound-guided (TUG) drainage as initial step. Endoscopic ultrasound-guided (EUS) interventions were proposed as another option but their efficacy in comparison with TUG procedures requires further evaluation.

ID: 3523881 ENDOSCOPIC ULTRASOUND-GUIDED RADIOFREQUENCY AND ETHANOL ABLATION FOR PANCREATIC NEUROENDOCRINE TUMORS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Endoscopic ultrasound-guided (EUS) radiofrequency (RFA) and ethanol ablation for pancreatic neuroendocrine tumors (PNETs) have been reported to have promising results in recent studies. We conducted a systematic review and meta-analysis studying the effectiveness and safety of EUS-RFA ablation as compared to EUS ethanol ablation.

Malignant uveal melanoma with metastatic recurrence to the pancreas: A case report

AbstractMetastatic pancreatic cancers are uncommon. The most common primary origins are renal, lung, breast, and colon cancer, with sarcoma and melanoma observed less commonly. Distinguishing a primary pancreatic cancer from a metastasis can be difficult based on various non‐invasive imaging studies but is crucial to assure appropriate management. We reported a rare case of malignant uveal melanoma (UM) with metastatic recurrence to pancreas diagnosed by endoscopic ultrasound‐guided (EUS) fine‐needle aspiration (FNA). Under best supportive care, the patient eventually died of disease progression with multiple liver and brain metastases. Prognosis remains poor for patients with metastatic UM owing to no significantly effective treatment. It is important for clinicians to be aware of the possibility of malignant UM metastasizing to intra‐abdominal organs even after primary resection.

Mesenchymal neoplasms of the tubular gut and adjacent structures: experience with EUS-guided fine-needle aspiration cytopathology

Unlike epithelial malignancies, mesenchymal neoplasms arising within the tubular gut are less often encountered in endoscopic ultrasound-guided (EUS) fine-needle aspiration biopsies (FNABs). Nonetheless, preoperative diagnosis of such neoplasms has important therapeutic and prognostic value. We report our experience with this category of neoplasms from the past decade. We performed a 10-year retrospective search at our respective institutions to identify EUS-guided FNAB cases of mesenchymal neoplasms arising from the tubular gut wall and closely adjacent structures. Cytopathologic diagnoses were compared to corresponding surgical pathology (SP) when available. Cases with either no confirmatory cell block (CB) immunohistochemical (IHC) staining, or no SP were excluded. Two-hundred eighty-two cases (M:F = 1:1; age range: 25-94 years, mean age = 60 years) of EUS-guided FNAB from the tubular gut met our criteria. Onsite adequacy was performed on nearly all cases. Case numbers: 209 gastrointestinal stromal tumors (GIST), 58 smooth muscle neoplasms, and 15 miscellaneous neoplasms. Of these, 188 (67%) had SP follow-up. We found that 258 (91%) aspirates had a correct specific diagnosis, 3 (1%) were nondiagnostic, 18 (6%) had indeterminate diagnoses, and 3 (1%) had incorrect diagnoses (2 leiomyosarcomas mistaken as leiomyoma, and 1 fibrosclerotic lesion mistaken as inflammatory pseudotumor). Of 94 cases with no SP, all had a specific cytologic diagnosis based on confirmatory IHC staining from the CB including 61 GISTs, 29 smooth muscle neoplasms, and 4 miscellaneous tumors. This study endorses the clinical utility of EUS-guided FNAB in the diagnosis of tubular gut mesenchymal neoplasms. A definitive and accurate diagnosis is possible in over 90% of cases, chiefly when cytomorphology is coupled with optimal cellularity and IHC from a concurrent CB. EUS-guided FNAB diagnosis of mesenchymal tubular gut neoplasms may play an important role in determining neoadjuvant therapy as targeted therapy evolves.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology.

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

Miniinvasive Step-up Strategy of Surgical Treatment in Different Phases of Acute Necrotizing Pancreatitis

Background: Surgical management of acute necrotizing pancreatitis (ANP) has evolved from primary laparotomic operation to wide application of minimal invasive interventions during last decades. Objective of our research was to establish strategy of application of miniinvasive interventional treatment during different phases of ANP. Material & Methods: We performed a prospective observational cohort study of 373 patients with ANP during 2013-2018. The following parameters were collected for each case: length of hospital stay, in-hospital mortality, presence of organ failure and local complications. Result(s): Surgical treatment was applied in 210 (57.8%) patients. We used the step-up approach of surgical treatment and started from either transcutaneous ultrasound-guided (TUG) in 102 (48.2%) or endoscopic ultrasound-guided (EUS) puncture/drainage in 97 (46.2%) observations. During shock phase only decompression fascitomy was performed in 6 (2.9%) cases with non-controlled intra-abdominal compartment syndrome. Necessary for interventional treatment occurred in 55 (26.2%) patients with infected acute necrotic collections (ANC) and 149 (73.8%) - with walled-off pancreatic necrosis (WOPN). Proactive TUG procedures and video-assisted retroperitoneal debridement (VARD) through nephroscope were followed by less complication rate in ANC cases whereas EUS and endoscopic necrosectomies – in WOPN observations. Wide laparotomic necrosectomies was applied in 46 (21.9%) of surgically operated patients after 4th week of disease. Pancreatic fistula occurred in 6.5%, hemorrhagic complications - 8.7%, new organ failures cases – 15.2%. Overall mortality rate was 3.3%, after interventional treatment – 6.5%. Conclusions: Surgical treatment in patients with ANP based on step-up approach is followed by acceptable complication and mortality level. Interventional treatment should be postponed on terms after 4th week whenever is possible with exception of patients with intra-abdominal compartment syndrome. In patients with ANC transcutaneous approach is followed by less complications rate whereas in WOPN cases endoscopic route is preferable.

2127 Splenic Abscess Management With a Lumen Apposing Metal Stent: Case Report

INTRODUCTION: Splenic abscess is an uncommon infection (incidence 0.5%) that if left untreated, could be fatal. The most common source of splenic abscesses is usually hematogenous spread from an infected source from another part of the body. The patient typically presents with fever, left upper quadrant pain, and/or splenomegaly. CT scan is the imaging modality of choice for diagnosing splenic abscess. Management of splenic abscess consists of antibiotic treatment and splenectomy. The use of percutaneous CT-guided drainage is a safer spleen-conserving alternative to surgery. In this case report , we describe novel approach, to treat splenic abscess via endoscopic ultrasound-guided (EUS) placement of a lumen apposing metal stent (AXIOS). CASE DESCRIPTION/METHODS: This is a 44 year old male with a past medical history significant for necrotizing pancreatitis and gastric varicies who presented to our center with fever and weakness. He was previously admitted 3 months prior with post ERCP necrotizing pancreatitis which was managed successfully with endoscopic therapy. The patient reported that on the day of admission, he developed a low-grade fever and lethargy. The abdomen was soft, mildly distended, with tenderness to palpation in the left and right lower quadrants. CT of the abdomen revealed a formation of a splenic abscess measuring 5 cm × 6.5 cm. Blood cultures were positive for ESBL and the patient was started on antibiotics. An EUS was performed that showed a splenic abscess and an abscessgastrostomy was successfully performed using a 10 × 10 mm lumen-apposing metal stent (LAMS). One week later a repeat EGD with debrivement and lavage of the abscess cavity was performed and a 10 F × 5 cm double pigtail stent was exchanged for the LAMS. On month later, a CT scan showed complete splenic abscess resolution and the double pigtail was removed. Six month CT scan showed no abscess recurrence. DISCUSSION: EUS has been described in the drainage of pelvic, mediastinal and intrabdominal abcess. In this report we describe the first use of lumen apposing metal stent for endoscopic management of a splenic abscesses. Lee et al first reported the use of EUS guided splenic abscess drainage with the use of a double pigtail stent. This approach showed to be safe and less invasive alternative to the standard of care. In cases of worsening clinical status and reported morbidities as high as 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic abscess.

The relationship between the PD-L1 expression of surgically resected and fine-needle aspiration specimens for patients with pancreatic cancer.

Recently, therapeutic antibodies against programmed death-1/programmed death-ligand 1 (PD-1/PD-L1) have shown promising clinical results for several solid tumors, including pancreatic cancer. In this study, we evaluated the relationship between the PD-L1 expression of surgical resected and fine-needle aspiration (FNA) specimens for patients with pancreatic cancer. Of 121 patients who underwent endoscopic ultrasound-guided (EUS)-FNA before surgery for pancreatic cancer in an academic center, the 94 (78%) with adequate FNA specimens for a histological evaluation were retrospectively analyzed. All the patients had undergone upfront surgery without any chemotherapy or radiotherapy. We performed immunohistochemistry (IHC) staining to investigate the PD-L1 expression in both resected and FNA specimens. The positive-stained cells were counted, and their percentage was used for the investigation. Of the 94 patients, 16 (17%) and 11 (10%) were defined as positive on resected cancer specimens using cutoff points of 5% and 10% positively stained cancer cell counts, respectively. The concordance rates for the positive frequency of PD-L1 expression between resected and FNA specimens were 44% (7/16) and 55% (6/11) when the positivity was set to ≥ 5% and ≥ 10%, respectively. The concordance rates for the negative frequency of PD-L1 expression between two specimens were 97% (76/78) and 99% (82/83) when the positivity was set to ≥ 5% and ≥ 10%, respectively. Approximately, half of the patients with PD-L1 expression positive and almost all the patients with PD-L1 expression negative could be diagnosed on FNA specimens.

Efficacy of endoscopic ultrasound-guided and endoscopic retrograde cholangiopancreatography-guided biliary drainage for malignant biliary obstruction: a systematic review and meta-analysis.

Endoscopic ultrasound-guided (EUS) biliary drainage was used as an alternative method for patients who failed endoscopic retrograde cholangiopancreatography (ERCP). In recent years, an increasing number of patients was treated with EUS-biliary drainage (BD), but lack of data was available to value the efficacy and safety between EUS and ERCP. Therefore, a review was needed to evaluate the similarities and differences between the two methods and explored whether EUS-guided biliary drainage could be considered as first-line treatment. We searched the Pubmed/Medline, Embase, Web of science, Google scholar, the Cochrane Library and Clinical trials of electronic databases till October 2018 for all English language. Primary outcomes to comparison included technical success, clinical success and adverse events. Secondary outcomes consisted of stent dysfunction requiring reintervention and procedure duration, Data from selected studies were collected to calculate the odds ratios (OR) and standard mean difference (SMD). We searched 469 studies and at last identified 4 eligible trials. These included a total of 428 patients, 215 in the EUS group and 213 in the ERCP group. There was no difference in technical success (OR, 0.95; 95% CI: 0.45-2.02; I2=0%), clinical success (OR, 0.87; 95% CI: 0.42-1.79; I2=0%) and adverse events between 2 procedures (OR, 0.76; 95% CI: 0.29-2.00; I2=55%) but EUS-BD consisted of lower rate of reintervention (OR, 0.30; 95% CI: 0.14-0.63; I2=0%),and fewer procedure-related adverse events in pancreatitis and cholangitis (OR, 0.14; 95% CI: 0.04-0.51; I2=0%).There was no difference in length of procedure duration, with a pooled standard mean difference of 0.26 (95% CI: -0.15 to 0.66). EUS-BD and ERCP-BD in terms of relief of malignant biliary obstruction presented the similarity rate of technical success, clinical success and there is no significant difference in adverse events of two procedures. EUS-BD could be used as a substitute for ERCP-BD, even considered as first-line treatment.

Optimization of an Endoscopic Radiofrequency Ablation Electrode

Radiofrequency ablation (RFA) is an increasingly used, minimally invasive, cancer treatment modality for patients who are unwilling or unable to undergo a major resective surgery. There is a need for RFA electrodes that generate thermal ablation zones that closely match the geometry of typical tumors, especially for endoscopic ultrasound-guided (EUS) RFA. In this paper, the procedure for optimization of an RFA electrode is presented. First, a novel compliant electrode design is proposed. Next, a thermal ablation model is developed to predict the ablation zone produced by an RFA electrode in biological tissue. Then, a multi-objective genetic algorithm is used to optimize two cases of the electrode geometry to match the region of destructed tissue to a spherical tumor of a specified diameter. This optimization procedure is then applied to EUS-RFA ablation of pancreatic tissue. For a target 2.5 cm spherical tumor, the optimal design parameters of the compliant electrode design are found for two cases. Cases 1 and 2 optimal solutions filled 70.9% and 87.0% of the target volume as compared to only 25.1% for a standard straight electrode. The results of the optimization demonstrate how computational models combined with optimization can be used for systematic design of ablation electrodes. The optimization procedure may be applied to RFA of various tissue types for systematic design of electrodes for a specific target shape.

Percutaneous Image-Guided Biopsy of the Pancreas

AbstractPercutaneous image-guided biopsy of the pancreas is a safe, effective, efficient, and minimally invasive way to obtain samples for pathological diagnosis of pancreatic mass lesions. The myriad of diseases that can involve the pancreas require different therapies. Therefore, pathological diagnosis is key. With proper imaging resources and techniques, most mass lesions of the pancreas that are visible on cross-sectional imaging can be approached safely and accurately percutaneously under either computed tomography (CT) or ultrasound guidance. These lesions may be accessed through anterior, posterior, and/or lateral approaches depending upon their proximity to the anticipated skin puncture site, and the presence or absence of intervening structures. While the ideal percutaneous route to any pancreatic target lesion is the one that has no vital structures in its path, methods and tools exist to make even the most seemingly obstructed paths to pancreatic targets navigable. Once accessed, the targets may be sampled by either fine-needle aspiration or core needle biopsy. The alternatives to percutaneous image-guided biopsy of the pancreas include open (surgical) biopsy and endoscopic ultrasound-guided (EUS) biopsy. Percutaneous image-guided biopsy poses less risk to the patient than open biopsy and has been shown to be as accurate as EUS biopsy with an even lower complication rate.

Follow-up of indeterminate cytologic diagnoses of solid pancreatic lesions: atypia versus suspicious (one institution's experience)

A comparison of the long-term risk of malignancy between indeterminate cytological diagnoses, namely, atypical versus suspicious for malignancy, from endoscopic ultrasound-guided (EUS) fine-needle aspiration (FNA) of a pancreatic mass has not been well characterized. The primary aim of this study was to compare the risk of malignancy between patients with such indeterminate diagnoses. Secondarily, we investigated whether serologic markers serve as predictors of risk of malignancy in the setting of indeterminate cytological diagnoses. We reviewed 484 cases of EUS-FNA on solid pancreatic lesions, performed at a single academic tertiary care center from 2004 to 2017. Patients with solid pancreas mass lesions who had atypical or suspicious final cytology were identified for further clinical outcome analysis. Of the 484 patients with pancreas mass lesions, 53 (11%) were given an indeterminate final cytologic diagnosis, with 28 atypical and 25 suspicious for malignancy. Follow-up was completed for 22 and 20 patients from atypical and suspicious diagnoses, respectively. Of patients with follow-up, 15 (68%) and 18 (90%) had subsequent diagnoses of malignancy from atypical and suspicious groups, respectively. There was no statistical difference in predicting risk of malignancy between the two groups (P = 0.24). Serologic markers were available in 29 of 42 patients with follow-up. Serologic markers were elevated in 21 of 29 patients and all were subsequently diagnosed with malignancy. Elevated serologic markers correlated with future risk of malignancy (P = 0.0026). The risk of subsequent malignancy is high for both atypical and suspicious pancreatic solid lesions but there exists no statistical difference between the two. Combined serologic markers with indeterminate cytology proved to be a good predictor of malignancy.

Endoscopic ultrasound-guided liver biopsy: a multicenter experience.

Background and aims: Endoscopic ultrasound-guided (EUS) liver biopsy (LB) is proposed as a newer method that offers several advantages over existing techniques for sampling liver tissue. This study evaluated the diagnostic yield of EUS-LB as the primary outcome measure. In addition, the safety of the technique in a large patient cohort was assessed. Patients and methods: Patients undergoing EUS for evaluation of elevated liver enzymes or hepatic disease were included in this prospective, non-randomized, multicenter study. EUS-LB was performed with EUS-fine needle aspiration (FNA; 19-gauge needle). Tissue was formalin-fixed and stained with hematoxylin and eosin, and trichrome. Using a microscope micrometer, specimen length was measured and the number of complete portal triads (CPTs) were counted. The main outcome measure was to assess the diagnostic yield of EUS-LB, and to monitor for any procedure-related complications. Results: Patients (110; median age, 53 years; 62 women) underwent EUS-LB at eight centers. The indication was abnormal liver enzymes in 96 patients. LB specimens sufficient for pathological diagnosis were obtained in 108 of 110 patients (98 %). The overall tissue yield from 110 patients was a median aggregate length of 38 mm (range, 0 – 203), with median of 14 CPTs (range, 0 – 68). There was no statistical difference in the yield between bilobar, left lobe only, or right lobe only biopsies. There was one complication (0.9 %) where self-limited bleeding occurred in a coagulopathic and thrombocytopenic patient. This complication was managed conservatively. Conclusions: EUS-guided LB was a safe technique that yields tissue adequate for diagnosis among 98 % of patients evaluated.

Telecytopathology for on-site adequacy evaluation decreases the nondiagnostic rate in endoscopic ultrasound-guided fine-needle aspiration of pancreatic lesions.

Advances in digital imaging methods have resulted in use of telecytology in the immediate assessment of fine-needle aspiration (FNA) specimens. We retrospectively compared the nondiagnostic rate for endoscopic ultrasound-guided (EUS) FNA of pancreatic lesions in two groups: one with on-site evaluation for adequacy via telecytopathology and the other without on-site adequacy evaluation. All patients undergoing EUS-FNA of pancreatic lesions over a 2-year period were included. Direct smears were immediately wet-fixed or air-dried, and any residual material was rinsed in saline for cell block or cytospin preparation. Patients were divided into two groups: Group 1 had on-site telecytopathology evaluation for adequacy by a cytopathologist, and Group 2 had no on-site adequacy evaluation. The cytologic diagnoses were reviewed, and the nondiagnostic rates for each group were calculated. The age, sex, and characteristics of pancreatic lesions (solid versus cystic) between the two groups were compared. In total, 217 patients were included. Telecytopathology on-site evaluation was provided for 95 (43.8%) cases. There was no difference between the groups in terms of age and sex. Pancreatic lesions were predominantly solid in the group that underwent telecytopathology on-site evaluation (p<0.005). The nondiagnostic rates for solid lesions in Group 1 and Group 2 were 3.7% and 25.6%, respectively (p<0.0001). Although the nondiagnostic rate for cystic lesion was higher in Group 2, it did not reach a level of statistical significance (16.5% versus 7.1%; p=0.249). After adjusting for the effects of sex and lesion characteristics (solid versus cystic lesion) with multivariate logistic regression, the odds of having a nondiagnostic specimen in Group 2 was 6.9 times greater than in Group 1, and the result was statistically significant (p=0.0013). Telecytopathology on-site evaluation of EUS-FNA of pancreatic lesions reduces the nondiagnostic rate, especially in lesions with solid characteristics, and may serve as an effective substitute for on-site evaluation by a cytopathologist.

Celiac Plexus Neurolysis for Abdominal Cancer Pain: A Systematic Review

This systematic review assesses the effectiveness and side effects of celiac plexus neurolysis (CPN) in the treatment of upper abdominal cancer pain, and evaluates whether there are any differences between the percutaneous and endoscopic ultrasound-guided (EUS) denervation techniques. Five databases were searched, expanded by assessing the reference lists of all retrieved papers. Sixty-six publications fulfilled the inclusion/exclusion criteria and were included in the systematic review. Randomized controlled trials were available for the percutaneous CPN, and therefore meta-analyses were performed for pain, opioid consumption, and specific side effects. The quality of life data were too heterogeneous to be assessed by a meta-analysis, and evidence for EUS CPN could only be evaluated by observational studies. Meta-analyses show that percutaneous CPN significantly improves pain in patients with upper abdominal cancer, with a decrease in opioid consumption and side effects. It is unclear whether there is any change in quality of life. Case series suggest that EUS CPN improves pain. No conclusion can be made about EUS CPN's influence on opioid consumption. Although CPN is a safe procedure, side effects and complications can occur with both the percutaneous and EUS techniques. Following this review, evidence suggests that CPN should be considered in patients with upper abdominal cancer where the pain is not adequately controlled with systemic analgesics or when significant opioid-induced side effects are present. The percutaneous approach remains the standard technique as robust evidence for EUS CPN is lacking.

Successful drainage of recurrent pancreatic pseudocyst via a transpapillary and transpancreatic approach, using a conventional cystotome

A 54-year-old patient was previously admitted to our hospital in 2010 with a history of biliary necrotizing pancreatitis and pancreatic fluid collection with necrotic debris projecting into the tail of the pancreas. We carried out endoscopic ultrasound-guided (EUS) transgastric drainage of the superinfected necrotic area. The patient was discharged and 6 months later the pigtails were removed after complete resolution of the fluid collection. After another 6 months, transabdominal ultrasound showed a large pseudocyst at the same site without any signs of inflammation. The diagnosis was confirmed by computed tomography (CT) (● Fig.1). EUS revealed a large stenosis in the pancreatic duct and there was suspicion of a fistula in relation to the pseudocyst. Transgastric access for pseudocyst drainage was impeded by the presence of multiple varices because of splenic vein thrombosis. We therefore chose a transpapillary approach for draining the pseudocyst (diameter 10cm). Endoscopic retrograde pancreatography (ERP) confirmed the presence of filiform stenosis in the pancreatic main duct and a prestenotic communication into the pseudocyst (● Fig.2). While a guide wire passed through the stenosis, neither an ERCP cannula nor a biliary dilatation catheter could be passed across it. After taking informed consent, another attempt was made to place the guide wire again via the stenosis into the pancreatic pseudocyst (● Fig.3). A cystotome was placed in the stenosis and moved under blended current into the pseudocyst (● Fig.4). A nasocystic tube was placed, which spontaneously drained 500mL of clear cystic fluid (● Fig.5). A follow-up CT scan revealed rapid and complete resolution of the pseudocyst, and 4 days later the patient had was discharged with a 17-cm, 7-F Amsterdam stent. There were no signs of discomfort or inflammation. This case demonstrates that access to a pancreatic pseudocyst for transpapillary drainage through a stenosed duct can be gained with a cystotome under blended current, so long as the guide wire is safely placed inside the pseudocyst. Fig.1 Computed tomography (CT) scan showing pancreatic pseudocyst in a patient with history of biliary necrotizing pancreatitis and pancreatic fluid collection with necrotic debris projecting into the tail of the pancreas.