EUS-guided tissue acquisition in patients with solid pseudopapillary neoplasms of the pancreas.

OBJECTIVES: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been the most common method used for the preoperative cytopathological diagnosis of solid tumors of the pancreas. There are only a few reported cases about the role of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in the pre-operative diagnosis of solid pseudopapillary neoplasms (SPN). This study aimed to evaluate the diagnostic yield of EUS-TA,including endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) andEUS-FNB, in patients with SPN. METHODS: We performed a retrospective analysis of patients with EUS-TA for SPN diagnosis in 2 referral centers. The primary outcome was the diagnostic yield of EUS-TA compared to the surgical specimen. RESULTS: Seventy-four patients with SPN of the pancreas were identified. Eighteen had a EUS-TA (10 EUS-FNB and 8 EUS-FNA). The median age of the patients was 31 years (IQR 21-38), and all patients were women. The most common presenting symptom was abdominal pain. Most of the tumors were in the head of the pancreas (9/18; 50%). The median tumor size by EUS was 4.5 cm (min-max 2-15 cm). The most common appearance on EUS was a solid lesion (n = 8/18, 44.4%). A definitive presurgical cytopathological diagnosis was obtained in 16/18 patients (88.8%) with EUS-TA. The sensitivity and positive predictive value of the EUS-TA were 94% each. One patient in the EUS-FNB group developed mild acute pancreatitis. CONCLUSION: The diagnostic yield of the EUS-TA in SPN is high. In most cases, the diagnosis was obtained with the first procedure. No differences in the diagnostic yield or AEs between EUS-FNA vs. EUS-FNB needles were seen.

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

BACKGROUND AND OBJECTIVES: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field. METHODS: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. RESULTS: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year. CONCLUSION: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy.

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.

The differential broadens. EUS FNA appearance and cytological findings of pancreatic angiomyolipoma.

CONTEXT: Angiomyolipoma is a rare tumor characterized histologically by a mixture of spindle cells, adipose tissue, epithelioid cells, and vascular tissue. It usually involves the kidney followed by the liver whereby the majority of affected patients are female, and many cases arise in the setting of tuberous sclerosis. CASE REPORT: We report a case of a 33-year-old female with an asymptomatic incidental right renal mass suggestive of an angiomyolipoma in conjunction with numerous pancreatic masses. CONCLUSIONS: The utility of EUS in the differential diagnosis of pancreatic tumors is well established. This is the first known reported EUS detection and FNA confirmation of angiomyolipoma metastatic to the pancreas and should now be added to the already broad differential of metastatic pancreatic tumors.

Self-expanding plastic stents in treatment of benign esophageal conditions.

BACKGROUND: Recently, self-expanding plastic stents (SEPSs) have been proposed for the treatment of benign esophageal disease. OBJECTIVES: Our purpose was to review our experience with SEPSs in patients with benign esophageal conditions. DESIGN: This was a retrospective case review of patients who underwent SEPS placement for benign esophageal disease, including (1) benign stricture, including reflux disease, ischemia, and idiopathic, (2) radiation-induced strictures, (3) anastomotic strictures, and (4) esophageal leak/fistulae. PATIENTS: Nineteen male and 11 female patients (average age 52.1 years, range 11-87 years) underwent SEPS placement. INTERVENTIONS: SEPS placement. MAIN OUTCOME MEASUREMENTS: Initial complications, stent migration, long-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging. RESULTS: Eighty-three of 84 SEPS placements were successful. The most common complications were chest pain, dysphagia, nausea, and vomiting. No deaths were reported from stent placement. Stent migration was more frequent in proximal (30/44 stents, 68.1%) and distal (19/27 stents, 70.4%) compared with mid esophageal (3/10 stents, 30%). Migration was more frequent in stents placed for benign strictures (18/22 stents, 81.8%), anastomotic strictures (18/24 stents, 75%), and fistulae/leak (13/22 stents, 59.1%) compared with radiation-induced strictures (4/14 stents, 28.6%). Only 5 of 83 interventions (6%) resulted in long-term improvement after stent removal. LIMITATIONS: This was a retrospective review, and patients were selected from a tertiary medical center. CONCLUSION: Use of SEPSs for benign esophageal conditions resulted in frequent stent migration and few cases of long-term improvement. Further investigation is warranted to identify optimal patient populations and to guide future recommendations for the use of SEPSs.

Evaluation of endoscopic approaches for deep gastric-muscle-wall biopsies: what works?

BACKGROUND: A major barrier to furthering our understanding of the pathophysiology of neuromuscular GI diseases, including functional GI disorders, is the inability to obtain deep gastric-wall biopsy specimens that include both layers of the muscularis propria, which allows evaluation of specific cell types, including myenteric ganglia. OBJECTIVES: The aims of this preclinical study were to (1) evaluate different endoscopic approaches for obtaining deep gastric-muscle-wall biopsy specimens and (2) determine if myenteric ganglia were present in the tissue samples. DESIGN AND INTERVENTIONS: This was a preclinical acute study by using a pig model. Multiple samples were obtained from 4 pigs. The endoscopic techniques evaluated were (1) EUS-guided tru-cut biopsy of the gastric wall, (2) jumbo biopsy of the post-EMR site, (3) jumbo biopsy of the gastrotomy margin, (4) serosal-side biopsy through a gastrotomy, and (5) double-EMR resection. MAIN OUTCOME MEASUREMENTS: Resected tissue was submitted for histology to determine which wall layers were included in the resected specimen. Hematoxylin and eosin staining was used to determine which muscle layers were biopsied, and an antibody to protein gene product 9.5 was used to determine if myenteric ganglia were present in the sample. RESULTS: Seventy-two tissue samples were obtained: EUS-guided tru-cut biopsy (n=16), jumbo biopsy of the post-EMR site (n=16), jumbo biopsy of the gastrotomy (n=16), serosal-side biopsy (n=16), and double-EMR resection (n=8). Only the double-EMR resection tissues showed the presence of longitudinal muscle, indicating the presence of both muscle layers and the myenteric plexus. Immunofluorescence studies demonstrated the presence of myenteric ganglia only in the double-EMR tissues and in none of the other gastric samples. No adjacent organs were included in the resection. CONCLUSIONS: The double-EMR technique was the only studied technique that resulted in a deep gastric-wall sample and provided sufficient tissue to evaluate both muscle layers and the intermuscular layer that contain myenteric ganglia. Further studies are needed to verify the efficacy and to assess the safety of this approach.

Tissue anchors for transmural gut-wall apposition.

BACKGROUND: With the development of NOTES (natural orifice transluminal endoscopic surgery) and efforts to advance gastric reduction surgery, alternatives for robust tissue apposition apart from suturing and current mucosal clipping devices may be valuable. OBJECTIVES: We attempted to identify functional tissue anchors that could be deployed endoscopically, with the potential to provide transmural tissue apposition. DESIGN: Short-term animal-survival study. PATIENTS: Domestic pigs, under general anesthesia, underwent open laparotomy, gastrotomy, and manual placement of prototype tissue anchors. INTERVENTIONS: Four tissue-anchor designs were evaluated (T bar, T bar with mesh bolster, star, basket). Full-thickness gastric plications were manually created in the body and the antrum via laparotomy and were secured with sets of paired anchors, also placed manually via a gastrotomy. In 1 test animal, a pilot gastric reduction was created by forming 2 rows of 4 anchor sets on the anterior and posterior walls to create a tubelike gastric lumen. MAIN OUTCOME MEASUREMENTS: Follow-up endoscopy was performed at 2, 4, and 9 weeks to visually assess the intraluminal appearance of the plications, followed by necropsy and histologic study. RESULTS: There was an overall attrition of the number of anchor sets. At 2 weeks, the T-bar anchors were first to disappear, and the mesh and the star designs began to pull through the gastric folds. At 4 weeks, there was flattening of the plications that involved 6 pairs of mesh anchors. By 9 weeks, 3 pairs of mesh anchors were lost and 3 pairs were associated with flattened folds. At the time of euthanasia, at 4 or 9 weeks, the number of retained anchors associated with intact plications for each group were as follows: T bar, 6 of 9 pairs (67%); mesh, 12 of 18 pairs (67%); basket, 14 of 18 pairs (78%); and star, 2 of 9 pairs (22%). There were no gastric adhesions and no evidence for any inflammatory changes surrounding the stomachs. The tallest plications involved the basket anchors. The basket-anchored plications contained apposed muscularis propria, with serosal fusion evident. The folds from the other anchor types were formed of mucosa and submucosa with or without superficial muscularis propria. CONCLUSIONS: The results of this experience are encouraging. The basket tissue anchors appear most promising. These findings suggest that further development of tissue anchors deployed via flexible catheter-based devices may have clinical value for transmural tissue apposition.