Comparing the diagnostic adequacy of 25-Gauge fork-tip versus franseen versus reverse-bevel-type needles in EUS-guided tissue acquisition: A prospective randomized study with a retrospective control.

Background and Objectives: EUS-guided fine-needle biopsy (FNB) is an established technique for the acquisition of tissue to diagnose lesions of the gastrointestinal tract and surrounding organs. Recently, newer-generation FNB needles have been introduced, including a second-generation reverse-bevel and the third-generation fork-tip and Franseen needles. We aimed to determine if there was any difference between these needles in terms of cytopathological diagnostic yield, sample cellularity, or sample bloodiness. Methods: One hundred twenty-seven consecutive patients undergoing EUS-guided FNB of any solid lesion were randomized to use either a Franseen or fork-tip needle in a 1:1 ratio and were compared with 60 consecutive historical cases performed with reverse-bevel needles. Patient and procedure characteristics were recorded. Cases were reviewed by a blinded cytopathologist and graded based on cellularity and bloodiness. Overall diagnostic yield was calculated for each study arm. Results: One hundred seventy-six cases were eligible for analysis, including 109 pancreatic masses, 24 lymphoid lesions, 17 subepithelial lesions, and 26 other lesions. The final diagnosis was malignancy in 127 cases (72%). EUS-guided FNB was diagnostic in 141 cases (80%) overall and in 89% of cases where malignancy was the final diagnosis. There was no difference in diagnostic yield, sample cellularity, or sample bloodiness between the different needle types. There was no difference in adverse events between groups. Conclusions: EUS-guided FNB performed using 25-gauge Franseen, fork-tip, and reverse-bevel needles resulted in similar diagnostic yield, sample cellularity, and sample bloodiness. Our results may not be extrapolated to larger-caliber needles of the same design.

Structured oropharynx, hypopharynx and larynx assessment during routine esophagogastroduodenoscopy improves detection of pre- and early cancerous lesions: a multicenter, comparative study.

Background and study aims A structured assessment of the oropharynx, hypopharynx and larynx (OHL) may improve the diagnostic yield for the detection of precancerous and early cancerous lesions (PECLs) during routine esophagogastroduodenoscopy (EGD). Thus, we aimed to compare routine EGDs ± structured OHL assessment (SOHLA), including photo documentation with regard to the detection of PECLs. Patients and methods Consecutive patients with elective EGD were arbitrarily allocated to endoscopy lists with or without SOHLA. All detected OHL abnormalities were assessed by an otolaryngologist-head & neck surgeon (ORL-HNS) and the frequency of PECLS detected during SOHLA vs. standard cohort compared. Results Data from 1000 EGDs with and 1000 EGDs without SOHLA were analyzed. SOHLA was successful in 93.3 % of patients, with a median assessment time of 45 seconds (interquartile range: 40-50). SOHLA identified 46 potential PECLs, including two benign subepithelial lesions (4.6 %, 95 % CI: 3.4-6.1) while without SOHLA, no malignant and only one benign lesion was found ( P  < 0.05). ORL-HNS imaging review classified 23 lesions (2.3 %, 95 % CI: 1.5-3.4) as concerning and ORL-HNS clinic assessment was arranged. This identified six PECLs (0.6 %, 95 % CI: 0.2-1.3) including two pharyngeal squamous cell lesions (0.2 %) demonstrating high-grade dysplasia and carcinoma in situ (CIS) and four premalignant glottic lesions (0.4 %) demonstrating low-grade dysplasia and CIS. Conclusion In the routine setting of a gastrointestinal endoscopy practice precancerous and early cancerous lesions of the oropharynx, hypopharynx, and larynx are rare (< 1 %) but can be detected with a structured assessment of this region during routine upper gastrointestinal endoscopy.

Endoscopic ampullectomy for non-invasive ampullary lesions: a single-center 10-year retrospective cohort study.

BACKGROUND: Lesions involving the ampulla of Vater have traditionally been managed by surgical resection, albeit with high rates of morbidity and mortality. Endoscopic ampullectomy is increasingly recognized as an efficacious and safer treatment option. This study aims to evaluate the safety and efficacy of endoscopic ampullectomy for non-invasive ampullary lesions in a single tertiary referral center. METHODS: Patients with non-invasive ampullary lesions, with or without familial adenomatous polyposis (FAP), were identified using pathology and endoscopy databases. The study included all patients who underwent the index ampullectomy between January 2007 and January 2017. Outcome parameters included accuracy of forceps biopsies, adverse events, success of endoscopic resection, and rate of recurrence. RESULTS: A total of 53 patients underwent endoscopic ampullectomy over the 10-year period. Histological upstaging was seen in 37.8% of cases at ampullectomy compared to biopsy, including 5 cases (9.4%) of invasive adenocarcinoma. Adverse events occurred in 10 patients (18.9%) consisting of bleeding (11.3%), benign papillary stenosis (3.8%), acute pancreatitis (1.9%), and duodenal perforation (1.9%). Recurrence occurred in 32.7% over a median follow-up of 30 months (range 6-104 months), with the majority (18.4%) occurring at the first surveillance endoscopy. Nonetheless, 75% of recurrences were able to be cleared endoscopically. Endoscopic resection was successful in 91.1% of patients. CONCLUSIONS: Endoscopic ampullectomy is an effective and safer therapeutic modality for non-invasive ampullary lesions, in addition to being a valuable diagnostic and staging tool. Nevertheless, careful patient selection and a commitment to endoscopic follow-up are of primary importance to achieve an optimal therapeutic outcome.

Is a Fundamental Design Change for Gastrointestinal Endoscopes Required?

Since the first fiberoptic instruments, gastrointestinal endoscopy has shaped the field of gastroenterology and is now a key diagnostic and therapeutic tool. Compared with the initial fiberoptic endoscopes state-of-the-art optical chips (or charge-coupled device technology) allowed a quantum leap in image quality. Despite these advances, gastrointestinal endoscopy is far from being perfect. The diagnostic yield (eg, for adenoma detection rates) is highly operator dependent and there is still the need for sedation or even anesthesia to address discomfort during the procedure. Despite highly standardized cleaning and high-level disinfection the reuse of contemporary (and difficult to clean) endoscopes with multiple channels exposes patients to the risk of transmission of infections. Artificial intelligence and pattern recognition should eliminate interindividual variability including polyp detection rates, self-propelled, and (potentially remotely controlled) scopes with a soft shaft could reduce the discomfort during procedures and abolish the need for sedation and anesthesia altogether and single-use designs should eliminate the risk of patient-to-patient transmission of infections. While these innovations are feasible and could be implemented rapidly utilizing available technology, they require a paradigm shift affecting all levels of the value chain from the supplier of the instruments to the end-users. Some may negate the need for a paradigm shift, but it is evident that a major redesign of the endoscopic equipment is overdue to fully utilize novel technologies and most importantly ensure the best possible outcomes for patients.

Splenic Injury Following Endoscopic Retrograde Cholangiopancreatography: A Case Report and Literature Review.

Splenic injury following endoscopy is a rare but potentially fatal complication. While this has been found to occur more frequently after colonoscopy, splenic injury following endoscopic retrograde cholangiopancreatography (ERCP) remains highly uncommon since its first reported case in 1989. Indeed, there have been only 19 such cases reported in the English, German, and Spanish literature collectively over the past 27 years. We report on a 59-year-old woman who developed a peri-splenic haematoma diagnosed on abdominal computed tomography the day following ERCP and stenting for Mirizzi syndrome. The patient was treated conservatively and made a full recovery. We reviewed all cases of post-ERCP splenic injuries reported to date and discuss the published opinions on the likely mechanism of injury, predisposing factors, presenting features, investigation, and treatment options. Ultimately, patient outcome relies on clinical suspicion of this rare complication following ERCP.

The scratch test for identifying the lower liver edge is at least as accurate as percussion and is significantly more effective for young trainees-a randomised comparative trial.

BACKGROUND: Clinical examination of the liver requires experience to achieve accuracy. The scratch test is a simple technique to identify the lower liver edge and enhance liver palpation, and may be easier for trainees. AIM: We aimed to evaluate the accuracy of the scratch test compared to percussion at different levels of medical training. METHOD: Eight examiners, from trainee intern to consultant level, were randomised to scratch or percussion testing, followed by liver palpation, on 50 subjects. Later, each examiner performed the alternative test on each subject. Confidence with each test was rated 0-3 (unsuccessful-very confident). Ultrasound scan (US) was performed as a reference for liver location. RESULTS: Ultrasound revealed 33/50 (66%) of livers extended below the right costal margin in the midclavicular line during quiet respiration (range 0.5-16cm). Of these, 33, 87% and 76% were identified within 2cm of the US location using scratch and percussion tests, respectively (p>0.05) for all examiners, but with significantly greater accuracy for the scratch test in young trainees (91% v 75%; p=0.016). Ability to palpate the liver was not different following either test. The training effect was assessed by comparing the accuracy results of the first 25 with the last 25 examined subjects, revealing a significant increase in accuracy with percussion from 71% to 85% (p=0.038) compared to no change with the scratch test (88% and 86%). Examiner confidence in the test result was significantly higher using the scratch test versus percussion, average confidence scores being 2.2 versus 1.8 (p<0.001), with a greater difference in the young trainee group at 2.4 versus 1.7 (p<0.001). CONCLUSION: The scratch test was at least as accurate as percussion overall in identifying the lower liver edge and significantly more accurate for the young trainees. The scratch test requires less training and in addition, all examiners and especially the young trainees were significantly more confident in their findings using the scratch test.

Achalasia: a 13-year, single-centre experience comparing endoscopic balloon dilatation and laparoscopic Heller myotomy.

BACKGROUND: Idiopathic achalasia is a non-curable, primary motility disorder of the oesophagus. Most established long-term palliative treatment options are laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (BD). AIM: We aimed to compare the outcome of both therapies and the risk of serious complications, defined as perforation or death, in a single-centre series. METHOD: In this retrospective study, patients with BD or LHM were identified from 1997-2010. The symptom score (modified Zaninotto score) before treatment and at time of interview was evaluated via a telephone questionnaire. RESULTS: Ninety-nine patients fulfilled the inclusion criteria and treatment was provided with BD-only in 63, surgery-only in 23, BD crossover to surgery in 12, and surgery crossover to BD in one patient. Mean age was 62 years in the BD-only, and 39 years in the surgery-only group. One hundred and fifteen BD were performed on 76 patients with multiple dilatations required in 46 patients (38%). Sixty-four percent of all patients alive (n=81) were interviewed. Satisfactory outcomes were achieved in 79% in the BD group and in 88% in the surgery group, with a mean follow-up of 81 and 69 months, respectively. There was a single perforation in the BD group (0.9%) and no deaths occurred. CONCLUSION: LHM and on-demand BD were safe and within the limitations of our study design both methods appeared similarly effective treatments for achalasia, resulting in a satisfactory outcome in 88% and 79% of patients with a mean follow-up of 69 and 81 months. Serious complications occurred in less than 1% of procedures and there were no deaths.

Autoimmune pancreatitis and primary sclerosing cholangitis in a 16-year-old boy with inflammatory bowel disease.

Autoimmune pancreatitis (AIP) is a rare systemic fibroinflammatory disorder. The disease usually occurs in elderly men and offers an excellent response to steroid treatment. AIP in childhood is exceedingly rare. We report the first case of AIP in a boy with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD). He presented with a six-year history of intermittent bloody diarrhoea. Colonoscopy revealed severe pancolitis and ileitis in keeping with IBD. Abnormal liver function tests and magnetic resonance cholangiopancreatography (MRCP) findings confirmed PSC and subsequent occurrence of renal lesions and pancreatic abnormalities on computed tomography imaging were suspicious for AIP. Immunoglobulin G4 (IgG4) serum levels were elevated and treatment with steroids led to complete resolution of renal lesions, pancreatic changes and normalization of IgG4 and liver function tests. Follow-up MRCP 6 months later revealed unchanged biliary abnormalities in keeping with PSC. The differentiation between PSC and extrapancreatic AIP affecting the biliary tree and liver is critical given the dramatic response of AIP to steroids. Recent recommendations therefore include IgG4 measurement in every adult with possible PSC. Our case documents for the first time that AIP has to be considered as a differential diagnosis in childhood PSC. IgG4 measurement should be recommended universally in possible PSC.

Allopurinol might improve response to azathioprine and 6-mercaptopurine by correcting an unfavorable metabolite ratio.

BACKGROUND AND AIM: Allopurinol potentiates azathioprine and 6-mercaptopurine (6-MP) by increasing 6-thioguanine nucleotide (6-TGN) metabolite concentrations. The outcome might also be improved by adding allopurinol in individuals who preferentially produce 6-methylmercaptopurine nucleotides (6-MMPN), rather than 6-TGN. The aim of the present study was to investigate the effect of allopurinol on concentrations of 6-MMPN and 6-TGN in individuals with a high ratio of these metabolites (>20), which is indicative of a poor thiopurine response. METHODS: Sixteen individuals were identified who were taking azathioprine or 6-MP, and were commenced on allopurinol to improve a high 6-MMPN:TGN ratio. Metabolite concentrations were compared before and after commencing allopurinol, and markers of disease control were compared. RESULTS: The addition of 100-300 mg allopurinol daily and thiopurine dose reduction (17-50% of the original dose) resulted in a reduction of the median (and range) 6-MMPN concentration, from 11,643 (3,365-27,832) to 221 (55-844) pmol/8×10(8) red blood cells (RBC; P=0.0005), increased 6-TGN from 162 (125-300) to 332 (135-923) pmol/8×10(8) RBC (P=0.0005), and reduced the 6-MMPN:6-TGN ratio from 63 (12-199) to 1 (0.1-4.5) (P=0.0005). There was a significant reduction in steroid dose requirements at 12 months (P=0.04) and trends for improvement in other markers of disease control. One patient developed red cell aplasia that resolved upon stopping azathioprine and allopurinol. CONCLUSIONS: In those with a high 6-MMPN:6-TGN ratio (>20), response to thiopurine treatment might be improved by the addition of allopurinol, together with a reduced thiopurine dose and close hematological monitoring.