Antonino Granata

Fully covered metallic stents in biliary stenosis after orthotopic liver transplantation

BACKGROUND AND STUDY AIMS Data from a preliminary study suggested that the placement of a fully covered metal stent may be a valid alternative to surgery in patients who do not respond to standard endoscopic treatment. The aims of the current study were to evaluate the clinical success of self-expandable metallic stents (SEMS) in a large cohort of patients and with a long followup,and the effectiveness of SEMS placement as a first-line procedure. MATERIALS AND METHODS Between January 2008 and August 2010, 54 consecutive patients with biliary complications following orthotopic liver transplantation were treated with SEMS placement:39 after failure of conventional endoscopic therapy (Group I), and 15 with no previous endoscopic treatment who were undergoing SEMS placement as first-line treatment for complications(Group II). RESULTS In Group I, resolution after SEMS removal was observed in 71.8% of patients. Mean followup after resolution was 22.1 ±10 months. Recurrence of the complication was observed in 14.3%of patients after a mean of 8.5 months and SEMS migration was observed in 33.3% of patients. In Group II, resolution was observed in 53.3% of patients.Mean follow-up after resolution was 14.4±2.2 months. Recurrence was observed in 25% of patients and SEMS migration was observed in 46.7 %. CONCLUSIONS For endotherapy of biliary complications after orthotopic liver transplantation, metallic stents should not be used as the primary modality. In patients in whom the standard approach fails, treatment with temporary SEMS placement can solve biliary complications in almost three-quarters of cases; however stent migration(33 %) remains a problem.

Pancreatic cystic lesions: How endoscopic ultrasound morphology and endoscopic ultrasound fine needle aspiration help unlock the diagnostic puzzle

Cystic lesions of the pancreas are being diagnosed with increasing frequency, covering a vast spectrum from benign to malignant and invasive lesions. Numerous investigations can be done to discriminate between benign and non-evolutive lesions from those that require surgery. At the moment, there is no single test that will allow a correct diagnosis in all cases. Endoscopic ultrasound (EUS) morphology, cyst fluid analysis and cytohistology with EUS-guided fine needle aspiration can aid in this difficult diagnosis.

Intraductal aspiration: a promising new tissue-sampling technique for the diagnosis of suspected malignant biliary strictures

BACKGROUND Brushing is the most commonly used technique for biliary sampling at ERCP, despite its limited sensitivity. OBJECTIVE To evaluate intraductal aspiration (IDA) as a new combined endoscopic technique for cytodiagnosis, its cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety. DESIGN Prospective, observational study. SETTING Single tertiary referral center. MAIN OUTCOME MEASUREMENTS IDA cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety. PATIENTS AND METHODS From April 2009 to September 2010, 42 consecutive patients with suspected malignant biliary stricture underwent ERCP, with tissue sampling obtained with IDA. IDA included performance of standard brushing in all patients. After standard brushing, to perform IDA, we removed the brush from its catheter and used the tip of the catheter as a scraping device. The tip was scraped back and forth across the stricture at least 10 times. The catheter and a suction line were connected to a specimen trap to obtain intraductal aspiration of fluids and samplings. RESULTS Our cytopathologists found adequate cellular yield in 39 of the 42 IDA samples (92.8%) versus 15 of the 42 brushing samples (35.7%) (P < .001). IDA showed a significantly higher sensitivity than brushing (89% vs 78% for adequate samples and 89% vs 37% for all samples) and provided significantly superior cellular adequacy (92.8% vs 35.7%). LIMITATIONS Observational study, small number of patients. CONCLUSIONS IDA significantly improves brushing cellular adequacy and has high sensitivity for cancer detection. It was also safe, simple, rapid, and applicable during routine diagnostic ERCP, with no additional costs.

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.

Covered self expandable metallic stent with flared plastic one inside for pancreatic pseudocyst avoiding stent dislodgement

Endoscopic ultrasound-guided drainage has recently been recommended for increasing the drainage rate of endoscopically managed pancreatic fluid collections and decreasing the morbidity associated with conventional endoscopic trans-mural drainage. The type of stent used for endoscopic drainage is currently a major area of interest. A covered self expandable metallic stent (CSEMS) is an alternative to conventional drainage with plastic stents because it offers the option of providing a larger-diameter access fistula for drainage, and may increase the final success rate. One problem with CSEMS is dislodgement, so a metallic stent with flared or looped ends at both extremities may be the best option. An 85-year-old woman with severe co-morbidity was treated with percutaneous approach for a large (20 cm) pancreatic pseudocyst with corpuscolated material inside. This approach failed. The patient was transferred to our institute for EUS-guided transmural drainage. EUS confirmed a large, anechoic cyst with hyperechoic material inside. Because the cyst was large and contained mixed and corpusculated fluid, we used a metallic stent for drainage. To avoid migration of the stent and potential mucosal growth above the stent, a plastic prosthesis (7 cm, 10 Fr) with flaps at the tips was inserted inside the CSEMS. Two months later an esophagogastroduodenoscopy was done, and showed patency of the SEMS and plastic stents, which were then removed with a polypectomy snare. The patient experienced no further problems.

Definitive outcomes of self-expandable metal stents in patients with refractory post-transplant biliary anastomotic stenosis.

BACKGROUND Endoscopic retrograde cholangio-pancreatography is the gold standard of treatment in patients with biliary complications after liver transplantation. The benefits of fully covered self-expandable metal stents (FCSEMS) lie in their relative simplicity and the need for only two procedures, one for insertion, and the other for removal. Several case series have been published on such stents with generally good outcomes. Objective is to analyze definitive long-term outcomes of this treatment. METHODS Prospective, observational study in a single, tertiary-care referral centre. All consecutive patients with post-transplant biliary stenosis/leak were treated with FCSEMS after failure of conventional treatment. Recurrence was evaluated after four years. RESULTS From February 2008 to April 2012, 70 patients were included. In all patients, the metal stent was successfully placed. After a mean of 86.7 ± 38.4 days, the stent was removed. Forty-six patients (65.7%) showed resolution. After a mean of 4 ± 1.2 years, 61% of patients maintained the results, but 39% showed recurrence. On the tested variables the diagnosis of stenosis, the number of previous procedures and plastic stents placed correlate with better long-term results. CONCLUSIONS This series suggests a lack of long-term advantages of FCSEMS over plastic stents in the management of biliary stenosis after liver transplantation.

Hemospray for multifocal bleeding following ultra‐low rectal endoscopic submucosal dissection

A 50-year-old woman with a 6-cm laterally spreading tumor (LST) of the rectum was referred to our institute. Colonoscopy confirmed the presence of the lesion, with rectal retroflexion showing LST margins over the dentate line and internal hemorrhoidal vessels (Fig. 1a). Histology revealed an adenomatous polyp with high-grade dysplasia. An ultra-low rectal endoscopic submucosal dissection (ESD) was carried out with a high-definition narrowband endoscope (GIF-H190; Olympus Medical, Center Valley, PA, USA) equipped with a water-jet HybridKnife T-Type (Erbe, Tubingen, Germany), which combined dissection with submucosal injection of saline mixed with diluted epinephrine (1:100 000) and indigocarmine (Fig. 1b). Multiple minor bleeding observed during ESD was controlled with submucosal injection or with HybridKnife coagulation. However, at the end of the procedure, multifocal post-ESD oozing bleeding was observed among the internal hemorrhoidal veins (Fig. 1c). To obtain complete hemostasis, and to avoid major bleeding from the internal hemorrhoids, Hemospray (Cook Medical, Winston-Salem, NC, USA) treatment was attempted. A 7-Fr catheter was advanced approximately 2 cm out of the scope and placed approximately 2 cm from the post-ESD ulcer. Multiple consecutive bursts created a hemostatic powder barrier, which successfully stopped all bleeding (Fig. 2). There were no adverse events or late recurrent bleeding. Endoscopic resection at the anorectal junction is technically challenging, and intraprocedural or delayed bleeding can occur. Hemospray is a novel inorganic mineral powder licensed for endoscopic treatment of non-variceal upper gastrointestinal bleeding that, when put in contact with blood, forms a coherent and adhesive hemostatic barrier. Furthermore, Hemospray application for lower gastrointestinal bleeding has also been reported. In our case, Hemospray was used to stop diffuse post-ESD oozing bleeding among the veins of the internal hemorrhoidal plexus. In conclusion, the present case suggests a new and potentially useful application of Hemospray for the treatment of difficult-to-treat post-ESD bleeding.

Buried stent: New complication of pseudocyst drainage with self-expandable metallic stent

A 41-year-old man, with a history of necrotic-hemorrhagic pancreatitis 3 years earlier, presented to our institute for magnetic resonance evidence of a large pancreatic pseudocyst. Attempts to drain the cyst with plastic stents and nose-cystic tube failed because of the presence of highly corpusculated intracystic fluid. We decided to insert a biliary, partially covered self-expandable metallic stent (PCSEMS) 4 cm ¥ 10 mm (Wallstent; Boston Scientific, Natick, MA, USA) under endosonography (EUS) guidance (Fig. 1a). A huge amount of corpusculated fluid drained from the stent (Fig. 1b). At 1 month, an endoscopic exam showed no presence of the PCSEMS in the gastric lumen, but did show evidence of a 2-cm mucosal bulging (Fig. 1c). Survey with a catheter showed a small fistulous orifice connected to the pseudocyst (Fig. 1d).With a pneumatic dilator we opened the fistular tract and saw the gastric extremity of PCSEMS embedded in the gastric wall, completely covered by the gastric mucosa, resembling the ‘buried bumper’ of complicated percutaneous endoscopic gastrostomy (PEG). Attempts to remove the PCSEMS were stopped because of bleeding.The patient was sent to surgery.The surgeon carried out a pseudocyst-jejunal anastomosis and removed the transgastric SEMS, the gastric extremity of which was firmly blocked in the gastric wall. Recent reports have documented the efficacy of selfexpandable metallic stents (SEMS) for drainage of pancreatic pseudocysts. We report the first case of pseudocyst drainage with a PCSEMS that resulted in a complication we have called ‘the buried stent’, one that resembles the ‘buried bumper’ of complicated PEG placement. Several methods could conceivably prevent this complication. We placed the metallic stent in a large fistula created from previous dilation. Recently, we have placed several covered self-expandable metallic stents (CSEMS) without fistular tract dilation and experienced no problems (unpubl. data). Other approaches could be to use completely covered SEMS or double pig-tail stents placed inside the CSEMS, or to use a larger stent, such as an enteral stent, or more-flared or newly designed stents which ensure more stability in the fistular tract.

Hemospray for treatment of acute bleeding due to upper gastrointestinal tumours

BACKGROUND Hemospray is a new endoscopic haemostatic powder that can be used in the management of upper gastrointestinal bleedings. AIMS To assess the efficacy and safety of Hemospray as monotherapy for the treatment of acute upper gastrointestinal bleeding due to cancer. METHODS The endoscopy databases of 3 Italian Endoscopic Units were reviewed retrospectively and 15 patients (8 males; mean age 74 years) were included in this study. RESULTS Immediate haemostasis was achieved in 93% of cases. Among the successful cases, 3 re-bled, one case treated with Hemospray and injection had a good outcome, while 2 cases died both re-treated with Hemospray, injection and thermal therapy. No complications related to Hemospray occurred. Finally, 80% of patients had a good clinical outcome at 30days and 50% at six months. CONCLUSION Hemospray may be considered an effective and safe method for the endoscopic management of acute neoplastic upper gastrointestinal bleedings.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of pancreatic schwannoma

A 34-year-old woman, with a previous history of abdominal rauma, presented with recurrent abdominal pain. Abdominal comuter tomography scan revealed a large septated solid-cystic lesion n the pancreatic head (Fig. 1A and B). Linear endoscopic ultrasound EUS) showed a 7-cm multiloculated solid-cystic lesion (Fig. 1C nd D). The mass was atypical for a pseudocyst, and more consisent with a cystic neoplasm. A single pass with a 22 gauge needle as performed for fluid aspiration and cytohistology of the solid omponent. Cystic fluid analysis showed carcinoembryonic antien (CEA) 1.4 ng/ml, carbohydrate antigen 19.9 (CA19.9) 23.4 UI/ml, nd amylase 34 U/l. These results were not suggestive of pseudocyst r mucinous neoplasm. Cytohistology (Fig. 2A) of the fine needle spiration (FNA) specimen with immunostaining for S100 (Fig. 2B) evealed a pancreatic schwannoma. Due to symptoms and the large ize of the lesion, the patient underwent surgical excision which onfirmed the diagnosis of benign pancreatic schwannoma. Schwannomas are rare neoplasms that originate from Schwann ells in the peripheral nerve sheath and usually occur in the xtremities, but can also be found in the trunk, head and neck, etroperitoneum, mediastinum, pelvis and rectum. Only 47 cases f pancreatic schwannomas were reported in the literature [1]. hese lesions frequently undergo cystic degenerative changes and orphologically may mimic other pancreatic cystic lesions so they re rare but important clinical entities to include in the differential iagnosis of pancreatic cystic lesions. EUS-FNA with immunostainng for S100 should be considered the best preoperative diagnostic pproach.