Amitpal S. Johal

Endoscopic ultrasound-guided liver biopsy: a multicenter experience.

Background and aims: Endoscopic ultrasound-guided (EUS) liver biopsy (LB) is proposed as a newer method that offers several advantages over existing techniques for sampling liver tissue. This study evaluated the diagnostic yield of EUS-LB as the primary outcome measure. In addition, the safety of the technique in a large patient cohort was assessed. Patients and methods: Patients undergoing EUS for evaluation of elevated liver enzymes or hepatic disease were included in this prospective, non-randomized, multicenter study. EUS-LB was performed with EUS-fine needle aspiration (FNA; 19-gauge needle). Tissue was formalin-fixed and stained with hematoxylin and eosin, and trichrome. Using a microscope micrometer, specimen length was measured and the number of complete portal triads (CPTs) were counted. The main outcome measure was to assess the diagnostic yield of EUS-LB, and to monitor for any procedure-related complications. Results: Patients (110; median age, 53 years; 62 women) underwent EUS-LB at eight centers. The indication was abnormal liver enzymes in 96 patients. LB specimens sufficient for pathological diagnosis were obtained in 108 of 110 patients (98 %). The overall tissue yield from 110 patients was a median aggregate length of 38 mm (range, 0 – 203), with median of 14 CPTs (range, 0 – 68). There was no statistical difference in the yield between bilobar, left lobe only, or right lobe only biopsies. There was one complication (0.9 %) where self-limited bleeding occurred in a coagulopathic and thrombocytopenic patient. This complication was managed conservatively. Conclusions: EUS-guided LB was a safe technique that yields tissue adequate for diagnosis among 98 % of patients evaluated.

Improved endoscopic retrograde cholangiopancreatography brush increases diagnostic yield of malignant biliary strictures

AIM To determine if a new brush design could improve the diagnostic yield of biliary stricture brushings. METHODS Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to protocol implementation in July 2011, after which, a new 9 French wire-guided cytology brush (Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pathologists who determined whether the sample was positive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen. RESULTS Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular findings consistent with malignancy as compared to 17 of 46 (37%) in the historical control group (P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes (21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to historical controls. CONCLUSION The use of a new brush design for brush cytology of biliary strictures shows increased diagnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clusters obtained.

Endoscopic ultrasound-guided liver biopsy in pediatric patients.

Endoscopic ultrasound (EUS) is routinely used for diagnostic and therapeutic purposes in adults, and there is emerging literature on its feasibility and safety in children. A recent novel application is EUS-guided liver biopsy (EUS-LB), which has shown to be technically simple, safe, and provides adequate diagnostic yield in adults for evaluation of liver disease; but the use of EUS-LB has never been evaluated in the pediatric population. We report the first case series of EUS-LB in the pediatric population, performed on 3 children, 1 girl and 2 boys-ages 9, 14 and 17 respectively, using a 19-gauge EUS-fine needle aspiration needle. All three cases were performed for the evaluation of unexplained elevated liver enzymes, with above-average diagnostic yield and without any immediate or delayed complications in all children. The use of EUS-LB was pivotal in the management of all the cases. Our case series illustrates the diagnostic utility and safety of EUS-LB in pediatric patients.

Heparin priming of EUS-FNA needles does not adversely affect tissue cytology or immunohistochemical staining

Background and study aims  Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) or biopsy (FNB) is an indispensable diagnostic tool. Improvements in needling technique have led to increasing tissue yields. Blood clogging of the needle can cause difficulties with specimen handling and stylet passage, which improves when the needle is primed with heparin before use. However, the effect of heparin on cytology, histology or immunochemistry (IHC) of FNA and FNB specimens is unknown. The goal of the study was to evaluate heparin priming on cytologic/histologic appearance, IHC staining, ease of stylet passage, and specimen bloodiness. Patients and methods  This was a retrospective study of patients undergoing EUS-FNA/FNB. Needle sizes were 25 gauge (g), 22 g, and 19 g. Heparin priming of the needle was done and the stylet replaced (“dry heparin”) or suction attached without replacing the stylet (“wet heparin”). Smears and cellblocks were examined by pathologists, and IHC staining were done as needed. Specimen bloodiness was compared with matched controls. Results  Adequate tissue yields were obtained in all samples (37 heparin, 36 no heparin). Heparin priming did not exhibit negative effects on cytologic or histologic interpretation of the specimens, nor IHC. There was no difference in cellblock bloodiness between the heparin primed needle specimens and the non-heparin control group.  Conclusions  Heparin priming of EUS-FNA or FNB needles does not negatively affect cytologic or histologic interpretation, nor interfere with IHC. In addition, heparin priming does not increase specimen bloodiness. When the “wet suction” technique is used for EUS-FNA, heparin priming can be used instead of saline priming of the EUS needle.

Heads or tails: confusion about “proximal” and “distal” terminology for pancreaticobiliary anatomy

Background and study aims  The anatomical meaning of the terms “proximal” and “distal” in relation to the pancreaticobiliary anatomy can be confusing. We aimed to investigate practice patterns of use of the terms “proximal” and “distal” for pancreaticobiliary anatomy amongst various medical specialties. Materials and methods  An online survey link to a normal pancreaticobiliary diagram was emailed to a multispecialty physician pool. Respondents were asked to label various parts of the common bile duct (CBD) and pancreatic duct (PD) using the terms “proximal,” “distal,” “not sure,” or “other.” Variability in use of these terms between specialties was assessed. Results  We received 370 completed surveys from 182 gastroenterologists (49.2 %), 97 surgeons (26.2 %), 68 radiologists (18.4 %), and 23 other physicians (6.2 %). There was overall consensus in describing the upper/sub-hepatic CBD as “proximal CBD” (73.8 %, P  = 0.1499) and the lower/pre-ampullary portion as “distal CBD” (84.6 %, P  = 0.1821). Conclusions  Although use of the terms “proximal” and “distal” is still very common to describe pancreaticobiliary anatomy, there is a discordance about its meaning, particularly for the PD. Use of descriptive terminology may be a more accurate alternative to prior ambiguous terminologies such as “proximal” or “distal” and can serve to improve communication and decrease the possibility of medical errors.

Endoscopic treatment of internal hemorrhoids by use of a bipolar system

Hemorrhoids occur in 4% of the population and are identified in 39% to 45% of colonoscopies. Internal hemorrhoids have been categorized further according to the Banov classification, which has grades I to IV. Although grades III and IV have typically been managed surgically, grades I and II can be treated by endoscopic means. Numerous endoscopic methods have been described to treat internal hemorrhoids, but these techniques are fraught with high rates of postprocedural pain. The described technique for hemorrhoidal therapy is a bipolar system that uses a novel anoscope with built-in illumination and a consistent compression apparatus (Figs. 1 and 2). This allows for stable energy delivery, which causes lower rates of collateral damage and, therefore, less postprocedural pain. This video (Video 1, available online at www.VideoGIE. org) demonstrates appropriate patient selection,

Cholangioscopic appearance after radiofrequency ablation of cholangiocarcinoma

Figure 1. To-scale view of intraductal radiofrequency ablation device showing an 8F, 180-cm, wire-guided catheter with 2 stainless steel electrodes covering 25 mm of intraductal space. An estimated 39,000 cases of cholangiocarcinoma (CC) were diagnosed in the United States in 2016. Of the patients with diagnoses of CC, two-thirds are unable to undergo surgical resection and require locoregional therapy. Given the ever-rising prevalence of this condition and the intimate involvement of the advanced endoscopist in the care of these patients, intraductal therapies have arisen, which may serve an important role in the care of CC. One such technology is an intraductal radiofrequency ablation (RFA) device, which uses an 8F, 180-cm wireguided catheter with 2 stainless steel electrodes covering 25 mm of the treatment site (Fig. 1). This technology allows for the delivery of RF energy within the biliary tree for the treatment of CC. An 81-year-old man with unresectable CC (due to multilobar disease), who had undergone 1 cycle of chemotherapy, presented for ERCP with stent exchange. His medical history included chronic obstructive pulmonary disease and coronary artery disease. His initial liver function values were minimally elevated, with an aspartate aminotransferase of 56 U/L, alanine aminotransferase of 62 U/L, total bilirubin of 2.1 mg/dL, and alkaline phosphatase of 286 U/L. The patient received a diagnosis of a 4.4 5.9 cm hyperintense mass with central enhancement, and a pronounced peripheral rim in the caudate lobe and mass in the left hepatic duct (Fig. 2). An ERCP demonstrated a prominent biliary tumor in the left main hepatic duct. Biopsy of the tumor was performed with intraductal forceps (Fig. 3). Additionally, during this procedure the patient underwent placement of a plastic biliary stent during the wait for the diagnosis (Fig. 4). Examination of these biopsy specimens later confirmed the diagnosis of CC. The patient was seen by medical and surgical oncologists during a multidisciplinary tumor board, and the plan was to give chemotherapy with concomitant locoregional therapy, using intraductal RFA to allow for maximal palliative effect and prolong the interval for stent exchange. During chemotherapy, the patient returned for ERCP, for which a 10F 15 cm plastic stent was placed. After the completion of 1 cycle of chemotherapy, CT was then performed for staging purpose and revealed an

Acute Pancreatitis Induced Fluid Collections - The Naming Game

Despite the publication of the “Revision of the Atlanta Classification and Definitions by International Consensus” [1], we have noted a continued variability in terminology used for reporting the types of pancreatic fluid collections complicating acute pancreatitis. In response to this perceived variability, we devised a survey to determine if the updated terminologies were being implemented in everyday practice. Our hypothesis was that physicians are still unclear on how to distinguish and name pancreatic fluid collections.