Fluorescence confocal microscopy for rapid evaluation of EUS fine-needle biopsy in pancreatic solid lesions.

Video 1EUS fine-needle biopsy of a pancreatic solid lesion evaluated with fluorescence confocal microscopy.

Endoscopic ultrasound-guided fine-needle biopsy with or without macroscopic on-site evaluation: a randomized controlled noninferiority trial.

BACKGROUND : The advantage of using the macroscopic on-site evaluation (MOSE) technique during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) performed with 22G Franseen needles has not been investigated. We aimed to compare EUS-FNB with MOSE vs. EUS-FNB performed with three needle passes. METHODS : This randomized trial involved 10 Italian referral centers. Consecutive patients referred for EUS-FNB of pancreatic or nonpancreatic solid lesions were included in the study and randomized to the two groups. MOSE was performed by gross visualization of the collected material by the endoscopists and considered adequate when a white/yellowish aggregate core longer than 10 mm was retrieved. The primary outcome was diagnostic accuracy. Secondary outcomes were specimen adequacy, number of needle passes, and safety. RESULTS : 370 patients with 234 pancreatic lesions (63.2 %) and 136 nonpancreatic lesions (36.8 %) were randomized (190 EUS-FNB with MOSE and 180 with standard EUS-FNB). No statistically significant differences were found between EUS-FNB with MOSE and conventional EUS-FNB in terms of diagnostic accuracy (90.0 % [95 %CI 84.8 %-93.9 %] vs. 87.8 % [95 %CI 82.1 %-92.2 %]; P = 0.49), sample adequacy (93.1 % [95 %CI 88.6 %-96.3 %] vs. 95.5 % [95 %CI 91.4 %-98 %]; P = 0.31), and rate of adverse events (2.6 % vs. 1.1 %; P = 0.28). The median number of passes was significantly lower in the EUS-FNB with MOSE group (1 vs. 3; P < 0.001). CONCLUSIONS : The accuracy of EUS-FNB with MOSE is noninferior to that of EUS-FNB with three needle passes. MOSE reliably assesses sample adequacy and reduces the number of needle passes required to obtain the diagnosis with a 22G Franseen needle.

A case of cystic paraduodenal pancreatitis with gastric outlet obstruction: technical pitfalls in EUS-guided gastroenteroanastomosis.

Video 1Technical pitfalls in EUS-guided gastroenteroanastomosis in an 84-year-old man with gastric outlet obstruction owing to cystic paraduodenal pancreatitis.

EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis-procedure outcomes and evaluation of mortality predictors.

BACKGROUND: Recent evidences suggest that gallbladder drainage is the treatment of choice in elderly or high-risk surgical patients with acute cholecystitis (AC). Despite better outcomes compared to other approaches, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is burdened by high mortality. The aim of the study was to evaluate predictive factors for mortality in high-risk surgical patients who underwent EUS-GBD for AC. METHODS: A retrospective analysis of a prospectively maintained database was performed. Electrocautery-enhanced lumen-apposing metal stents were used; all recorded variables were evaluated as potential predictive factors for mortality. RESULTS: Thirty-four patients underwent EUS for suspected AC and 25 (44% male, age 78) were finally included. Technical, clinical success rate and adverse events rate were 92%, 88%, and 16%, respectively. 30-day and 1-year mortality were 12% and 32%. On univariate analysis, age-adjusted Charlson Comorbidity Index (CCI) (OR 20.8[4-68.2]), acute kidney injury (AKI) (OR 21.4[2.6-52.1]) and clinical success (OR 8.9[1.2-11.6]) were related to 30-day mortality. On multivariate analysis, CCI and AKI were independently related to long-term mortality. Kaplan-Meier curves showed an increased long-term mortality in patients with CCI > 6 (hazard ratio 7.6[1.7-34.6]) and AKI (hazard ratio 11.3[1.4-91.5]). CONCLUSIONS: Severe comorbidities and AKI were independent predictive factors confirming of long-term mortality after EUS-GBD. Outcomes of EUS-GBD appear more influenced by patients' conditions rather than by procedure success.

The Role of Contrast-Enhanced Harmonic Endoscopic Ultrasound in Interventional Endoscopic Ultrasound.

Over the last decades, contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) has emerged as an important diagnostic tool for the diagnosis and differentiation of several gastrointestinal diseases. The key advantage of CH-EUS is that the influx and washout of contrast in the target lesion can be observed in real time, accurately depicting microvasculature. CH-EUS is established as an evidence-based technique complementary to B-mode EUS to differentiate solid appearing structures, to characterize mass lesions, and to improve the staging of gastrointestinal and pancreatobiliary cancer. In the last few years, interest has increased in the use of CH-EUS in interventional procedures such as tissue acquisition, tumor ablation, biliary drainage, and the management of pancreatic fluid collections. The aim of this narrative review is to evaluate the available evidence and future expectations of CH-EUS in interventional EUS.

Endoscopic mucosal resection of large colonic laterally spreading tumors using a dedicated viscous solution for submucosal injection (ORISE gel): a short case series (with video).

OBJECTIVE: Endoscopic mucosal resection (EMR) of large (>20 mm) laterally spreading tumors (LSTs) was usually rescheduled to guarantee experienced operator and enough endoscopic schedule time. The use of viscous solutions allows a reduction in repeated injections, snare resections and procedural time. The aim was to describe the outcome of EMR of large LSTs performed at the time of index colonoscopy, using ORISE gel (Boston Scientific). METHODS: A retrospective analysis was performed retrieving patients who underwent EMR of large colonic LSTs at the time of index colonoscopy. EMR was performed after dynamic injection of ORISE gel to create a submucosal cushion. Procedural parameters, together with pathological and endoscopic outcomes, were analyzed. RESULTS: Five patients [three males, median age 65 (45-70) years] were included. Median LST size was 35 mm (25-40). Median procedure time was 8 min (range 3-13). En bloc resection was achieved in one out of five cases; four out of five were planned as piecemeal resections. A median of 10 mL (10-20) of viscous solution was injected. R0 resection was achieved in the single case who underwent en bloc EMR, whereas it was not assessable in the case of piecemeal resections. One self-limiting bleeding was observed. CONCLUSION: The use of ORISE gel allows a well-tolerated and rapid performance of EMR of large colonic LSTs even at the time of index colonoscopy. In our opinion, in these specific situations, the use of viscous solutions is advisable and also affordable.