A new micro-forceps for endoscopic ultrasound-guided through-the-needle biopsy in the diagnosis of pancreatic cystic lesions: Single center experience.

BACKGROUND AND AIM: Endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCNs). Recently, a new through-the-needle micro-forceps device (Micro Bite, MTW Endoskopie Manufakture) has been introduced. The primary aim was to assess the safety and technical success of this new type of micro-forceps. The secondary aim was to evaluate the diagnostic role of EUS-TTNB. METHODS: Retrospective study of consecutive patients receiving EUS-TTNB for the diagnosis of PCNs. Two micro-forceps were used: Moray Micro-forceps and Micro-Bite. Cystic fluid was collected for cytological analysis. Categorical variables were analyzed by Fisher's exact test, and continuous variables were analyzed by Student's t-test. P < 0.05 was considered significant. RESULTS: Forty-nine patients enrolled in the study (24% male; mean age 63 ± 14 years). TTNB was successfully performed in all patients. A diagnostic sample was obtained in 67.3% PCNs with TTNB compared with 36.7% with cyst fluid cytology (P 0.01). Adverse events rate was 10.2% and occurred in older patients (76.6 ± 5.4 vs 61.3 ± 13.7 P = 0.02). The 51% underwent EUS-TTNB with Micro Bite. A diagnostic sample was obtained in 52% PCNs with Micro Bite compared with 24% obtained with cyst fluid cytology (P = 0.07). Comparing the two devices, the rate of diagnostic sample obtained with the micro-forceps Moray was higher than that obtained with the Micro Bite (20/24 [83.3%] vs 13/25 [52%] P 0.03). CONCLUSIONS: EUS-TTNB increases the diagnostic yield of PCNs. The new Micro-Bite could represent a valid alternative to the currently used Moray Micro-forceps, but its diagnostic rate is still suboptimal and further studies are needed.

Laser ablation of the biliary tree: in vivo proof of concept as potential treatment of unresectable cholangiocarcinoma.

OBJECTIVES: The palliative treatment of cholangiocarcinoma is based on stent placement with well-known procedure-related complications. Consequently, alternative energy-based techniques were put forward with controversial long-term results. This study aims to evaluate the safety and effectiveness of biliary tree laser ablation (LA) in terms of: (i) absence of perforation, (ii) temperature increase, (iii) induced thermal damage in in vivo models. MATERIALS AND METHODS: The common bile duct and cystic ducts of two pigs were ablated with a diode laser (circumferential irradiation pattern) for 6 and 3 min at 7 W. Laser settings were chosen from previous ex vivo experiments. Local temperature was monitored through a fibre Bragg grating (FBG) sensor embedded into the laser delivery probe. Histopathological analysis of the ablated specimen was performed through in situ endomicroscopy, haematoxylin and eosin (H&E) and nicotinamide adenine dinucleotide (NADH) stains. RESULTS: Temperature reached a plateau of 53 °C with consequent thermal damage on the application area, regardless of laser settings and application sites. No perforation was detected macroscopically or microscopically. At the H&E stain, wall integrity was always preserved. The NADH stain allowed to evaluate damage extension. It turned out that the ablation spreading width depended on application time and duct diameter. In situ endomicroscopy revealed a clear distinction between ablated and non-ablated areas. CONCLUSIONS: The temperature distribution obtained through LA proved to induce a safe and effective intraductal coagulative necrosis of biliary ducts. These results represent the basis for further experiments on tumour-bearing models for the treatment of obstructive cholangiocarcinoma.

Clinical management of gastroesophageal junction tumors: past and recent evidences for the role of radiotherapy in the multidisciplinary approach.

Gastroesophageal cancers (such as esophageal, gastric and gastroesophageal-junction -GEJ- lesions) are worldwide a leading cause of death being relatively rare but highly aggressive. In the past years, a clear shift in the location of upper gastrointestinal tract tumors has been recorded, both affecting the scientific research and the modern clinical practice. The integration of pre- or peri-operative multimodal approaches, as radiotherapy and chemotherapy (often combined), seems promising to further improve clinical outcome for such presentations. In the past, the definition of GEJ led to controversies and confusion: GEJ tumors have been managed either grouped to gastric or esophageal lesions, following slightly different surgical, radiotherapeutic and systemic approaches. Recently, the American Joint Committee on Cancer (AJCC) changed the staging and classification system of GEJ to harmonize some staging issues for esophageal and gastric cancer. This review discusses the most relevant historical and recent evidences of neoadjuvant treatment involving Radiotherapy for GEJ tumors, and describes the efficacy of such treatment in the frame of multimodal integrated therapies, from the new point of view of the recent classification of such tumors.

Temperature monitoring and lesion volume estimation during double-applicator laser-induced thermotherapy in ex vivo swine pancreas: a preliminary study.

Tissue temperature distribution plays a crucial role in the outcome of laser-induced thermotherapy (LITT), a technique employed for neoplasias removal. Since recent studies proposed LITT for pancreatic tumors treatment, assessment of temperature and of its effects around the laser applicator could be useful to define optimal laser settings. The aims of this work are temperature monitoring and measurement of ablated tissue volume in an ex vivo porcine pancreas undergoing double-applicator LITT. A three-dimensional numerical model is implemented to predict temperature rise and volumes of ablated tissue in treated pancreas. Experiments are performed to validate the model, with two modalities: (1) 12-fiber Bragg grating sensors are adopted to monitor the heating and cooling during LITT at several distances from the applicators tip, and (2) 1.5-T MR imaging is used to estimate the ablated volume. Experimental data agree with theoretical ones: at 2 mm from both applicators tips, the maximum temperature increase is approximately 60 °C downward from the tips, while it increases of about 40 °C and 30 °C, respectively, at the level and upward from the tips. This behavior occurs also at other distances, proving that the tissue downward from the tip is mostly heated. Furthermore, the estimated volume with MRI agrees with theoretical one (i.d., 0.91 ± 0.09 vs. 0.95 cm(3)). The encouraging results indicate that the model could be a suitable tool to choose the optimal laser settings, in order to control the volume of ablated tissue.

A mocking finding: portal cavernoma mimicking neoplastic mass. First sign of myeloproliferative disorder in a patient with Janus kinase2 V617F mutation.

The most important systemic etiological factors for portal thrombosis are the thrombophilic conditions associated with myeloproliferative disorders (MPDs), either clinically manifest or so-called 'occult'. Latest studies have revealed a strong association between MPDs and a somatic point mutation (V617F) of the tyrosine kinase Janus kinase2. The 'pseudo-cholangiocarcinoma sign' is a well described radiological finding related to portal cavernoma. We describe the case of a 48-year-old man, presenting with cavernomatous transformation of an extrahepatic thrombotic obstruction of the portal vein mimicking a neoplastic mass of the hepatic hilum, who did not present any other cause for thrombosis except for the V617F Janus kinase2 mutation, suggesting an underlying MPD.