Charilaos Papafragkakis

Endoscopic ultrasound-guided placement of AXIOS stent for drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) have conventionally been treated with surgery, percutaneous drainage, or with the more recently established endoscopic ultrasound (EUS)-guided drainage modality. Currently, endoscopic plastic or metallic stents are used for PFC drainage. Plastic stents present issues with stent migration and premature occlusion requiring frequent stent exchanges or placement of additional stents. Metallic stents are tubular and may migrate, resulting in inefficient drainage, content leakage, retrieval and replacement, and possible mucosal injury. The aim of this review was to summarize and evaluate the clinical and technical effectiveness of EUS-guided placement of the recently developed AXIOS stent, a lumen-apposing self-expandable metallic stent (LASEMS)for PFC drainage. A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 298 patients were included across all studies described thus far in the literature. Overall, a 97% technical success rate and a 96% clinical success rate have been reported. Early and late complications related to the placement or removal of LASEMS have been reported, however few cases have presented life-threatening results. EUS-guided PFC drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of adrenal lesions.

The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) appears to be a safe and feasible means of confirming or excluding malignancy in the adrenal glands. EUS-FNA with biopsy of suspicious masses in either adrenal gland allows for assessment of these lesions while keeping complications relatively rare. The main advantages of EUS-FNA are that it can be done as an outpatient procedure, with good results, minimal morbidity, and a short hospital stay. Nevertheless, EUS-FNA of adrenal masses should be indicated only in selected cases, in which there is potential to either decrease unnecessary treatment or guide therapy in cancer patients by aiding in either staging of malignancy or treatment of recurrence.v

Acute Hepatitis after Ingestion of a Preparation of Chinese Skullcap and Black Catechu for Joint Pain.

Many herbal preparations are routinely used and have been occasionally associated with a wide range of side effects, from mild to severe. Chinese skullcap and black catechu are herbal medications commonly used for their hepatoprotective and other properties. We report a case of acute toxic hepatitis associated with ingestion of Chinese skullcap and black catechu in one preparation for the alleviation of joint pain.

Endoscopic ultrasound-guided placement of the lumen-apposing self-expandable metallic stent for gallbladder drainage: a promising technique.

Acute cholecystitis and other clinical problems requiring gallbladder removal or drainage have conventionally been treated with surgery, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage of the gallbladder and/or extrahepatic bile duct. Patients unable to undergo these procedures due to functional status or anatomical anomalies are candidates for endoscopic ultrasound (EUS)-guided gallbladder drainage with stent placement. The aim of this review was to evaluate the technical feasibility and efficacy of EUS-guided placement of the recently developed lumen-apposing self-expandable metallic stent (LASEMS). A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 78 patients were included across all studies described thus far in the literature. Studies have reported near 100% technical and clinical success rates in selected cases. No major complications were reported. EUS-guided gallbladder drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and biopsy (FNB) has been widely accepted as a fundamental procedure for the diagnosis and staging of lesions of the gastrointestinal tract or non-gastrointestinal lesions within reach of the aspiration needle. EUS-FNA has been used in lesions of the esophagus, mediastinal lesions, lymph node (LN) sampling, lung cancer diagnosis and other less common conditions (such as tuberculosis and sarcoidosis), gastrointestinal subepithelial lesions, pancreatic solid cystic lesions and neuroendocrine tumors, liver and bile duct lesions (such as cholangiocarcinoma and hepatocellular carcinoma), rectal and pelvic lesion, and lesions of extra-gastrointestinal organs (such as the adrenals and the prostate). Continued improvements in the technology and the technical aspects of EUS-guided FNA and FNB aim to improve the diagnostic accuracy and sensitivity and at the same time reduce the adverse events associated with the procedure. This chapter focuses on common technical aspects of EUS-FNA and FNB, such as the choice of needle and use of the stylet and suction, and performs a short review of the current applications of EUS-guided FNA in gastrointestinal and extra-intestinal lesions, along with a brief review of the adverse events that have been associated with the procedure.

EUS of an atypical ectopic pancreas

A 43-year-old woman presented with abdominal pain, nausea, and vomiting. She underwent computed tomography of the abdomen and pelvis that showed a gastric subepithelial mass. Esophagogastroduodenoscopy (EGD) revealed a smooth subepithelial mass in the fundus of the stomach, 5 cm distal to the gastroesophageal junction [Figure 1]. EUS demonstrated a homogeneous, hypoechoic 14 mm × 9.7 mm lesion, originating in the gastric submucosa [Figure 2]. The pancreas had an unremarkable endosonographic appearance. EUS-FNA was performed with a 22-gauge needle. While endosonographic appearance and location were most suspicious for gastrointestinal stromal tumors (GISTs), cytology was surprisingly consistent with an ectopic pancreas (EP).

Primary Jejunal Adenocarcinoma Presenting as Bilateral Ovarian Metastasis

Small intestinal tumors are rare with adenocarcinoma of the small intestine accounting for less than 2% of all gastrointestinal cancers. Primary jejunal adenocarcinoma constitutes a minute portion of small intestine adenocarcinomas. Clinically, this cancer presents at latter stages of its progression, mainly due to vague and non-specific symptoms, and the difficulty encountered in accessing the jejunum on upper endoscopy. Diagnosis of jejunal adenocarcinoma is usually inconclusive with the use of computed tomography (CT) scan, small bowel series, or upper endoscopy. Laparoscopy followed by frozen section biopsy provides a definitive diagnosis. In the past decade, balloon-assisted enteroscopy (BAE) and capsule endoscopy have become popular as useful modalities for diagnosing small bowel diseases. Wide excisional jejunectomy is the only treatment option with an estimated 5-year survival of 40-65%. Physicians are advised to suspect jejunal adenocarcinoma as a differential diagnosis in patients who present with non-specific symptoms of abdominal pain, nausea, vomiting, weight loss, anemia, gastrointestinal bleeding or signs of small bowel obstruction. We present a rare case of a 37-year-old woman with suspected bilateral ovarian masses, which was immunohistochemically confirmed as primary jejunal adenocarcinoma with bilateral ovarian metastasis.

Mo1168 Urgent Endoscopy Within 12 Hours of Admission Is Associated With Decreased ICU Length of Stay and Overall Length of Stay

Background/Aim: Our study assessed five scoring systems (APACHE II, Charlson comorbidity index, AIMS65, Rockall score, and Glasgow-Blatchford score) for predicting intensive care unit (ICU) length of stay (LOS) and overall LOS in patients admitted to ICU for gastrointestinal bleeding (GIB) at a community teaching hospital.Methods:We prospectively studied all cases of GIB in patients admitted to the ICU from December 2013 to October 2014. Patients were included if they were 18 years of age or older, admitted directly to an ICU from the emergency department, had a hemoglobin (Hb) value of less than 10 g/dL or had a decrease in baseline Hb of at least 2 g/dL within the first 6 hours of admission. Pregnant women and patients with bleeding disorders were excluded. Patient demographics, clinical presentation, laboratory data, and endoscopic findings were recorded to calculate the scoring systems. ICU LOS and overall LOS were also recorded. SPSS 7.0 was used to calculate a Pearson correlation (r) for each independent scoring system and LOS. Results: 64 patients (60% male and 40% female) were included in the study. The mean age was 66 years (range 20-95). Mean ICU LOS was 4 days, whereas the mean overall LOS was 8 days. APACHE II (r=+0.345, p=0.005), AIMS65 (r=+0.412, p=0.001), Charlson comorbidity index (r=+0.497, p= 0.0001), Rockall (r=+0.402, p=0.001) and Glasgow-Blatchford (r=+0.301, p= 0.014) scores had statistically significant positive correlations to overall LOS. ICU LOS was significantly correlated with only APACHE II (r=+0.260, p=0.035) and Charlson comorbidity index (r=+0.309, p=0.011). Conclusion: APACHE II, Charlson comorbidity index, AIMS65, Rockall and Glasgow-Blatchford scores are positively correlated with overall LOS in patients admitted to ICU for GIB. However, only APACHE II and Charlson comorbidity index were significantly associated with ICU LOS.