Effectiveness and safety of serial endoscopic ultrasound-guided celiac plexus block for chronic pancreatitis.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound - guided celiac plexus block (EUS-CPB) is an established treatment for pain in patients with chronic pancreatitis (CP), but the effectiveness and safety of repeated procedures are unknown. Our objective is to report our experience of repeated EUS-CPB procedures within a single patient. PATIENTS AND METHODS: A prospectively maintained EUS database was retrospectively analyzed to identify patients who had undergone more than one EUS-CPB procedure over a 17-year period. The main outcome measures included number of EUS-CPB procedures for each patient, self-reported pain relief, duration of pain relief, and procedure-related adverse events. RESULTS: A total of 248 patients underwent more than one EUS-CPB procedure and were included in our study. Patients with known or suspected CP (N = 248) underwent a mean (SD) of 3.1 (1.6) EUS-CPB procedures. In 76 % of the patients with CP, the median (range) duration of the response to the first EUS-CPB procedure was 10 (1 - 54) weeks. Lack of pain relief after the initial EUS-CPB was associated with failure of the next EUS-CPB (OR 0.17, 95 %CI 0.06 - 0.54). Older age at first EUS-CPB and pain relief after the first EUS-CPB were significantly associated with pain relief after subsequent blocks (P = 0.026 and P = 0.002, respectively). Adverse events included peri-procedural hypoxia (n = 2) and hypotension (n = 1) and post-procedural orthostasis (n = 2) and diarrhea (n = 4). No major adverse events occurred. CONCLUSIONS: Repeated EUS-CPB procedures in a single patient appear to be safe. Response to the first EUS-CPB is associated with response to subsequent blocks.

Agreement in interpreting villous elements and dysplasia in adenomas less than one centimetre in size.

BACKGROUND: Villous elements and dysplasia grade in small adenomas are used in many countries to guide post-polypectomy colonoscopy intervals. AIMS: Measure agreement in interpretation of villous elements and dysplasia in small adenomas. METHODS: Consecutive endoscopically resected adenomas <10mm in size (203 adenomas less than 6mm and 149 adenomas 6-9 mm in size) were reviewed by 3 expert gastrointestinal pathologists. Interpretations were compared to routine clinical pathology readings at our institution and to each other. RESULTS: All pathologists used the same definitions for villous and tubular histology. The overall kappas for villous elements in <6mm and 6-9 mm adenomas were 0.29 and 0.26, respectively. Interpretation of dysplasia grade had kappas of 0.02 and 0.09 for adenomas <6mm and 6-9 mm, respectively. Two expert pathologists who used cytologic criteria had much higher fractions of high grade dysplasia compared to the third expert and the pathologists at our centre, who relied on architectural criteria. CONCLUSIONS: Villous elements and dysplasia grade in small adenomas are problematic as determinants of post-polypectomy surveillance intervals. Uniform pathologic criteria for dysplasia grade are needed.

Improving protection against proximal colon cancer by colonoscopy.

Colonoscopy protection against proximal cancer can be achieved, but the level of protection has thus far been less than left colon protection. Improved proximal protection begins with effective right colon bowel preparation, best achieved by split dosing the preparation regimen. Cecal intubation in screening examinations should exceed 95%, and must be documented by photography. Examiners must be proficient in detection of subtle right colon lesions, including serrated lesions as well as flat and depressed adenomas. Effective examination should be demonstrated by meeting recommended targets for adenoma detection.