Colon ischemia: A comprehensive review.

The clinical and endoscopic features of colon ischemia (CI) are non-specific. CI is correctly identified at the time of presentation in only 9% of patients is. The true incidence is likely underestimated because many mild cases resolve spontaneously without medical treatment. Furthermore, since most cases of CI are transient, and no specific cause is detected they are often considered to be "idiopathic". In the setting of severe CI correct diagnosis and prompt recognition and therapy as well as identification of underlying causes are crucial for a favourable outcome. Although less severe, mild cases may present with similar symptoms, the prognosis and management are completely different and managed conservatively rather than with surgery. Unfortunately, data from most studies and current guidelines do not provide recommendations on the long-term management of CI or about the need for endoscopic follow-up to detect the development chronic, recurrent and/or ischemic colonic strictures. In this review, we focus on the definition of CI, its aetiology, and patterns of presentation. We highlight the pharmacological and/or endoscopic management as determined severity of disease that allow for improved outcomes. Prompt recognition and treatment using a multidisciplinary approach are essential for successful management of severe CI because mortality rates are significantly higher when the diagnosis is delayed.

The presence of rapid on-site evaluation did not increase the adequacy and diagnostic accuracy of endoscopic ultrasound-guided tissue acquisition of solid pancreatic lesions with core needle.

BACKGROUND: Rapid on-site evaluation (ROSE) improves the adequacy and accuracy of EUS-guided tissue acquisition, although it is not routinely widely available. Evidence suggested that core needles might overcome the absence of ROSE. The aim of this study was to evaluate the influence of ROSE on the adequacy and accuracy of EUS-guided tissue acquisition with core needles in patients with pancreatic solid lesions. METHODS: Patients who underwent EUS-guided tissue acquisition of pancreatic mass lesions were retrospectively identified at three tertiary referral centers and those performed with the core needle were included. Adequacy, defined as the rate of cases in which a tissue specimen for proper examination was achieved, with and without ROSE was the primary outcome measure. The diagnostic accuracy and tissue core acquisition were the secondary outcome measures. RESULTS: A total of 333 patients with pancreatic solid mass lesions were included in the study; 140 cases sampled with ROSE and 193 cases without ROSE. The adequacy was 92.1 % in the group sampled with ROSE and 88.1 % in the group without ROSE (p = 0.227). In the ROSE group sensitivity, specificity, and accuracy were 90.7, 100 and 92.1 %, respectively. In the group without ROSE, sensitivity, specificity, and accuracy were 87.2, 100, and 88.1 %, respectively. No difference for all these figures was observed between the two groups. The tissue core was available in 61.4 and 53.4 % of cases with and without ROSE, respectively (p = 0.143). CONCLUSION: In the absence of ROSE, EUS-based tissue acquisition with Core needle should be considered since it achieves comparable tissue sampling adequacy and accuracy.

Reliability of endoscopic ultrasound in predicting the number and size of common bile duct stones before endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic ultrasound (EUS) is accurate for the diagnosis of choledocholithiasis; however, data are lacking regarding the prediction of stone number and size. AIMS: To evaluate the concordance between EUS and endoscopic retrograde cholangiopancreatography (ERCP) in stone number and size assessment. METHODS: We performed a retrospective analysis of consecutive patients undergoing ERCP due to detection of choledocholithiasis by EUS. Concordance between EUS and ERCP was defined as difference in stone diameter <30% and perfect match in stone number. RESULTS: Among 116 patients, 25% had sludge, 37.9% had single and 37.1% had multiple stones. Overall concordance was 62.9%. Sludge was correctly assessed in 85.7%, single stone in 81.3% and multiple stones in 45.1% (P=0.0001). EUS was accurate in 78.8% of patients who underwent both procedures in the same session, but only in 61.9% in those who underwent ERCP within 1 week. Multivariate analysis identified the single-session approach (odds ratio 2.894; P=0.035) and multiple stones (odds ratio 0.244; P=0.001) as independent predictors of concordance. CONCLUSIONS: Concordance between EUS and ERCP was correlated to the single session approach and inversely correlated to the presence of multiple stones. EUS may predict potentially difficult ERCP allowing to plan the best treatment strategy.

Gallstone ileus treated with non-surgical conservative methods: a case report.

INTRODUCTION: The preoperative diagnosis of gallstone ileus is challenging due to the variability of its presentation, often resulting in late diagnosis. Controversy remains regarding the management of gallstone ileus; surgery is the standard treatment, but also less invasive approaches have proven to be successful. We present an unusual case of gallstone ileus and its conservative treatment. CASE PRESENTATION: We describe the case of a 49-year-old Caucasian woman with a bowel sub-occlusion, treated conservatively. The imaging technique (plain abdominal X-ray and computed tomography scan) led to a diagnosis of gallstones ileus. A surgical intervention was not performed. Instead, she underwent extracorporeal shock-wave lithotripsy to fragment the stones, mechanical intestinal dilatation for ileocolic stenosis and endoscopic removal of the gallstone. The presence of an apricot shell contributed to the bowel occlusion and was removed. The intervention was successful and without complications. CONCLUSIONS: Given the variability of the gallstone ileus presentation, surgery could not be the only treatment for our patient. In our case report, we show that colonoscopy could be a non-invasive approach that allows for diagnosis and treatment at the same time. The available data do not show a higher rate of recurrent biliary disease in cases where this method has been used, therefore in select patients, a conservative treatment could be an effective solution.

Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions using a 22-gauge needle with side fenestration.

BACKGROUND: Early detection of small pancreatic cancer is important because expected survival is markedly better for tumors ≤ 2 cm. A new endoscopic ultrasound-(EUS) guided biopsy needle with side fenestration has been recently developed to enable fine-needle biopsy (FNB) under EUS guidance. The aim of this study was to evaluate the outcome of EUS-FNB using a 22-gauge ProCore needle in solid pancreatic lesions ≤ 2 cm, in terms of diagnostic accuracy and yield. METHODS: From January 2011 to December 2012, all consecutive EUS-guided tissue sampling of small pancreatic lesions (≤ 2 cm) were performed using 22-gauge ProCore needles; the data of these patients were analyzed retrospectively. RESULTS: Sixty-eight patients with a mean age of 65.7 years were included. The mean lesion size was 16.5 mm (range 5-20). None of the patients developed complications. On pathological examination, the tissue retrieved was judged adequate in 58 out of 68 cases (85.3 %) and the presence of a tissue core was recorded in 36 out of 68 cases (52.9 %). The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80, 100, 100, 40, and 82 %, respectively. CONCLUSION: Our results suggested that EUS-FNB of small pancreatic lesions using a 22-gauge ProCore needle is effective and safe, and supports our hypothesis that EUS-FNB is highly useful in establishing the nature of small pancreatic lesions.

Is diagnostic accuracy of fine needle aspiration on solid pancreatic lesions aspiration-related? A multicentre randomised trial.

BACKGROUND: Endoscopic ultrasound fine needle aspiration has a central role in the diagnostic algorithm of solid pancreatic masses. Data comparing the fine needle aspiration performed with different aspiration volume and without aspiration are lacking. We compared endoscopic ultrasound fine needle aspiration performed with the 22 gauge needle with different aspiration volumes (10, 20 and 0 ml), for adequacy, diagnostic accuracy and complications. METHODS: Prospective clinical study at four referral centres. Endoscopic ultrasound fine needle aspiration was performed with a 22G needle with both volume aspiration (10 and 20 cc) and without syringe, in randomly assigned sequence. The cyto-pathologist was blinded as to which aspiration was used for each specimen. RESULTS: 100 patients met the inclusion criteria, 88 completed the study. The masses had a mean size of 32.21±11.24 mm. Sample adequacy evaluated on site was 87.5% with 20 ml aspiration vs. 76.1% with 10 ml (p=0.051), and 45.4% without aspiration (20 ml vs. 0 ml p<0.001; 10 ml vs. 0 ml p<0.001). The diagnostic accuracy was significantly better with 20 ml than with 10 ml and 0 ml (86.2% vs. 69.0% vs. 49.4% p<0.001). CONCLUSIONS: A significantly higher adequacy and accuracy were observed with the 20 ml aspiration puncture, therefore performing all passes with this volume aspiration may improve the diagnostic power of fine needle aspiration.

Next generation sequencing improves the accuracy of KRAS mutation analysis in endoscopic ultrasound fine needle aspiration pancreatic lesions.

The use of endoscopic ultrasonography has allowed for improved detection and pathologic analysis of fine needle aspirate material for pancreatic lesion diagnosis. The molecular analysis of KRAS has further improved the clinical sensitivity of preoperative analysis. For this reason, the use of highly analytical sensitive and specific molecular tests in the analysis of material from fine needle aspirate specimens has become of great importance. In the present study, 60 specimens from endoscopic ultrasonography fine needle aspirate were analyzed for KRAS exon 2 and exon 3 mutations, using three different techniques: Sanger sequencing, allele specific locked nucleic acid PCR and Next Generation sequencing (454 GS-Junior, Roche). Moreover, KRAS was also tested in wild-type samples, starting from DNA obtained from cytological smears after pathological evaluation. Sanger sequencing showed a clinical sensitivity for the detection of the KRAS mutation of 42.1%, allele specific locked nucleic acid of 52.8% and Next Generation of 73.7%. In two wild-type cases the re-sequencing starting from selected material allowed to detect a KRAS mutation, increasing the clinical sensitivity of next generation sequencing to 78.95%. The present study demonstrated that the performance of molecular analysis could be improved by using highly analytical sensitive techniques. The Next Generation Sequencing allowed to increase the clinical sensitivity of the test without decreasing the specificity of the analysis. Moreover we observed that it could be useful to repeat the analysis starting from selectable material, such as cytological smears to avoid false negative results.

Complications of endoscopic ultrasound fine needle aspiration on pancreatic cystic lesions: final results from a large prospective multicenter study.

BACKGROUND: Endoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been reported to have a higher complication rate than that of solid lesions, but the real complication rate is unknown. Aim of the study was to identify the complication rate of endoscopic ultrasound-guided fine needle aspiration and related risk factors. METHODS: Prospective multicenter study at four referral centres. Data were collected from January 2010 to July 2012, searching for all adverse events related to guided fine needle aspiration. All complications occurring up to day 90 were recorded. RESULTS: 298 patients (43.9% male, mean age 63.2 ± 15.4 years) underwent endoscopic ultrasound-guided needle aspiration of pancreatic cystic lesions. Mean size was 34.1 ± 9 mm. Adverse events occurred in 18 patients (6%): mild complications in 12/18 (66.6%), and moderate complications in 6/18 (33.3%). Seven were immediate, 6 early, and 5 late. All resolved with medical therapy. CONCLUSIONS: Endoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been found to be associated with a higher complication rate than for solid lesions; however, the risk rate is acceptable considering the complication grade and the important diagnostic role of the technique in the management of pancreatic cystic lesions.

Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions.

BACKGROUND: Cytologic diagnosis by endoscopic ultrasound-guided fine needle aspiration is associated with low sensitivity and adequacy. A newly designed endoscopic ultrasound-guided fine needle biopsy device, endowed with a side fenestration, is now available. AIMS: We carried out a study with the aim of evaluating the feasibility, safety, and diagnostic yield of the 22-gauge needle with side fenestration for endoscopic ultrasound fine needle aspiration and biopsy of pancreatic cystic lesions. METHODS: 58 patients with 60 pancreatic cystic lesions consecutively referred for endoscopic ultrasound guided-fine needle aspiration were enrolled in a prospective, dual centre study, and underwent fine needle aspiration and biopsy with the 22-gauge needle with side fenestration. RESULTS: Fine needle aspiration and biopsy was technically feasible in all cases. In 39/60 (65%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. In lesions with solid components, and in malignant lesions, adequacy was 94.4% (p = 0.0149) and 100% (p = 0.0069), respectively. Samples were adequate for histologic evaluation in 18/39 (46.1%) cases. There were only 2 (3.3%) mild complications. CONCLUSIONS: Fine needle aspiration and biopsy with the 22-gauge needle with side fenestration is feasible, and superior to conventional endoscopic ultrasound-guided fine needle aspiration cytology from cystic fluid, particularly in pancreatic cystic lesions with solid component or malignancy, with a higher diagnostic yield and with no increase in complication rate.

Preoperative diagnosis of a solid pseudopapillary tumour of the pancreas by Endoscopic Ultrasound Fine Needle Biopsy: A retrospective case series.

BACKGROUND: A solid pseudopapillary tumour of the pancreas (SPTP) is a rare neoplasm. AIM: We herein present five cases of SPTP diagnosed using endoscopic ultrasound (EUS) guided fine-needle biopsy (FNB) using a needle with side fenestration (ProCore-needle). METHODS: From January 2011 to June 2012 in five patients with SPTP tissue acquisition was carried out with a 19-gauge (4 patients) or a 22-gauge (one patient) needle. RESULTS: The mean age of the patients was 30.8 years, the mean lesion size was 49mm and the most common location was the tail of the pancreas (3 cases). When the samples were evaluated macroscopically, small core fragments were observed in all cases. A preoperative diagnosis of SPTP was made in all patients on the basis of the histocytological and characteristic immunophenotypic patterns and was confirmed at final surgical histology. CONCLUSIONS: In our experience, EUS-FNB is an effective and secure method for a preoperative diagnosis of SPTP.

The role of K-ras gene mutation analysis in EUS-guided FNA cytology specimens for the differential diagnosis of pancreatic solid masses: a meta-analysis of prospective studies.

BACKGROUND: Differential diagnosis of pancreatic solid masses with EUS-guided FNA (EUS-FNA) is still challenging in about 15% of cases. Mutation of the K-ras gene is present in over 75% of pancreatic adenocarcinomas (PADC). OBJECTIVE: To assess the accuracy of K-ras gene mutation analysis for diagnosing PADC. DESIGN: We systematically searched the electronic databases for relevant studies published. Data from selected studies underwent meta-analysis by use of a bivariate model providing a pooled value for sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve. SETTING: Meta-analysis of 8 prospective studies. PATIENTS: Total of 931 patients undergoing EUS-FNA for diagnosis of pancreatic solid masses. INTERVENTION: K-ras mutation analysis. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of K-ras mutation analysis and of combined diagnostic strategy by using EUS-FNA and K-ras mutation analysis in the diagnosis of PADC. RESULTS: The pooled sensitivity of EUS-FNA for the differential diagnosis of PADC was 80.6%, and the specificity was 97%. Estimated sensitivity and specificity were 76.8% and 93.3% for K-ras gene analysis, respectively, and 88.7% and 92% for combined EUS-FNA plus K-ras mutation analysis. Overall, K-ras mutation testing applied to cases that were inconclusive by EUS-FNA reduced the false-negative rate by 55.6%, with a false-positive rate of 10.7%. Not repeating EUS-FNA in cases in which mutation testing of the K-ras gene is inconclusive would reduce the repeat-biopsy rate from 12.5% to 6.8%. LIMITATIONS: Small number of studies and between-study heterogeneity. CONCLUSION: K-ras mutation analysis can be useful in the diagnostic work-up of pancreatic masses, in particular when tissue obtained by EUS-FNA is insufficient, and the diagnosis inconclusive.

Placement of a new fully covered self-expanding metal stent for postoperative biliary strictures and leaks not responding to plastic stenting.

Fully covered self-expanding metal stents (FCSEMSs) are now being used to treat postoperative biliary strictures (BSs) and biliary leaks (BLs). The aim of this study was to assess the safety and effectiveness of a new FCSEMS (Wallflex) in patients with postoperative BSs and BLs after failure of traditional endoscopic treatment. Between January 2010 and December 2011, 16 patients (10 patients with postcholecystectomy BSs, 4 with postcholecystectomy BLs, and 2 with postorthotopic liver transplantation BSs) were enrolled. The technical and clinical success rate was 100%. All FCSEMSs were removed after a mean of 141 days. Complications occurred in 7 cases: 2 postprocedure pain, 2 mild pancreatitis, 1 early distal, and 2 late proximal FCSEMS migration. The overall long-term clinical success rate was 94% after a mean follow-up of 13 months. In our experience, the placement of FCSEMSs is an effective and secure method of treating refractory postoperative BSs or BLs.

Meta-analysis of randomized trials comparing endoscopic stenting and surgical decompression for colorectal cancer obstruction.

PURPOSE: Surgical decompression is the traditional treatment for acute colorectal cancer obstruction. In recent years, colorectal stenting has been used to relieve the obstruction. This study used meta-analytic techniques to compare colonic stenting versus surgical decompression for colorectal cancer obstruction. METHODS: A comprehensive search of several databases was conducted. The search identified 321 potential abstracts and titles of which eight randomized trials involving 353 patients were retrieved in full text. A meta-analysis of the studies included was carried out to identify the differences in outcomes between the two procedures. RESULTS: The pooled analysis showed no significant differences for mortality (odds ratio (OR) 0.91) and morbidity (OR 2.05) rates between the two strategies while the permanent stoma creation rate was significantly higher in the surgical group as compared to the stent group (OR 3.12). By comparing surgery and colonic stenting in studies which analyzed the use of stenting as a "bridge to surgery," the pooled analysis showed that primary anastomosis was more frequent in the stent group as compared to the surgical group (OR 0.42), and the stoma creation was more frequent in the surgical group as compared to the stent group (OR 2.36). CONCLUSION: Our study suggested that, in patients with acute colorectal cancer obstruction, stent placement improved several outcomes, such as primary anastomosis, stoma formation, and permanent stoma, while it failed to show an improvement in mortality and morbidity risk.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections.

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in "one step", EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

Simultaneous EUS-FNA Diagnosis and TNM Staging of a Pancreatic Neuroendocrine Tumor in a Patient with an Unrecognized MEN Type 1.

We report the case of a woman who, during oncological followup for bronchial carcinoid (diagnosed in 2005), papillary thyroid carcinoma, and bilateral parathyroid adenoma (simultaneously diagnosed in 2007), performed a pancreatic endoscopic ultrasonography with fine needle agobiopsy (EUS-FNA) for a positron emission tomography (PET) suspicion of pancreatic and hepatic lesions; during the procedure, the pancreatic and liver lesions were confirmed, and a peripancreatic lymph node involvement was found, allowing a complete pTNM staging during the same procedure.

24-h pH-metry and multichannel intraluminal impedance monitoring in obese patients with and without gastroesophageal reflux disease symptoms.

BACKGROUND: The 24-h ambulatory pH-metry with multichannel intraluminal impedance monitoring (24-h pH-metry+MII) allows the simultaneous assessment of chemical and physical properties of esophageal refluxes and the detection of its proximal migration. METHODS: Gastroesophageal reflux (GER) was investigated in obese symptomatic (obese gastroesophageal reflux disease, GERD) and asymptomatic (obese non-GERD) patients. The data were compared with those obtained from non-obese GERD patients and a control group. Thirty-five (20 non-GERD, 15 GERD) obese patients and 15 non-obese GERD were investigated with 24-h pH-metry+MII. Ten normal weight subjects with normal 24-h pH-metry+MII were used as control group. RESULTS: The percent time acid exposure was significantly higher in obese non-GERD than controls (p = 0.007). Acid reflux episodes were increased vs. controls in obese non-GERD (p = 0.005) and obese GERD (p = 0.034). Upright position showed a significant increase of reflux episodes in non-obese GERD (p = 0.034) and in obese non-GERD (p = 0.027) vs. controls. Recumbent position showed reflux episodes significantly increased vs. controls in obese non-GERD (p = 0.002), obese GERD (p = 0.021), and non-obese GERD (p = 0.033). In obese non-GERD, waist circumference (WC) correlated negatively with upright position episodes (r = -0.53; p = 0.043) and with proximal migration episodes, i.e., total (r = -0.60; p = 0.018), acid (r = -0.55; p = 0.033), and weakly acidic refluxes (r = -0.56; p = 0.031). CONCLUSIONS: Obese patients showed an increased number of refluxes with acid content. Refluxes with proximal extent were significantly higher in obese non-GERD than in controls and non-obese GERD patients. No difference was observed between the two obese patient groups. In asymptomatic obese patients, the WC correlated with proximal extent episodes.

Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis.

BACKGROUND AND AIM: Endoscopic ultrasonography (EUS) is a minimally invasive diagnostic tool for common bile duct stones (CBDS) and may be used to select patients for therapeutic endoscopic retrograde cholangiography (ERC). The aim of this trial is to compare, in patients with non-high-risk for CDBS, the clinical and economic impact of EUS plus ERC performed in a single endoscopic session versus EUS plus ERC in two separate sessions. METHODS: During an 11-month period, all adult patients admitted to the emergency department with suspicion of CBDS were categorized into either high-risk or non-high-risk groups, on the basis of clinical, biochemical, or transabdominal ultrasound findings. Patients in the non-high-risk group were randomized to receive EUS plus ERC in one single or in two separate sessions. RESULTS: Eighty patients were recruited and randomized. Forty patients underwent EUS plus ERC in a single session and 40 patients underwent EUS plus ERC in two separate sessions. Negative EUS examination for CBDS avoided unnecessary ERC to 33 patients. Out of 47 patients with positive EUS (25 from the single session group and 22 from the double session), ERC confirmed the presence of CBDS in 46 cases (EUS sensitivity 100% and specificity 98%). Average time of procedure and hospitalization were significantly shorter in the single session group compared to the two session group. The single session strategy was also less expensive. CONCLUSION: Endoscopic ultrasonography plus ERC with sphincterotomy and stone extraction performed during the same endoscopic session was safe and efficacious with a reduction of procedure time, hospitalization and costs.