Chris M. Hamerski

Yield and Performance Characteristics of Endoscopic Ultrasound-Guided Fine Needle Aspiration for Diagnosing Upper GI Tract Stromal Tumors

Background and AimsEUS-FNA is a means of sampling suspected GI stromal tumors (GIST). However, there are limited published data on factors influencing the sampling yield, and on the performance characteristics of this technique in comparison with resection pathology. We analyzed the yield of EUS-FNA for submucosal lesions of the upper GI tract, and determined the performance characteristics of EUS-FNA for diagnosing GISTs.MethodsWe retrospectively reviewed procedural and pathology data from consecutive patients undergoing EUS-FNA of submucosal lesions from two medical centers over a 4-year period. We analyzed the yield of EUS-FNA, and calculated performance characteristics of EUS-FNA for GIST based on resection pathology.ResultsA total of 65 patients underwent EUS-FNA of 66 submucosal lesions during the study period. EUS-FNA was either diagnostic (68%) or suspicious (12%) in a total of 80%. EUS-FNA yielded the following diagnoses: GIST based on cytology and immunohistochemistry (56%), suspected GIST (12%), leiomyoma (9%), other neoplasm (3%), and non-diagnostic (20%). Larger lesion size, gastric location, and presence of on-site cytopathology were associated with higher yield in univariate analysis. Larger needle size and number of FNA passes were not associated with improved yield. Based on resection pathology from 28 specimens, the EUS-FNA performance characteristics for diagnosing GISTs included a sensitivity of 82%, a specificity of 100%, and an overall accuracy of 86%.ConclusionsEUS-FNA provides a high yield for sampling submucosal lesions and is highly accurate for diagnosing GISTs. EUS-FNA has an important role in the evaluation of suspected GISTs.

A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy *

Background and study aims: Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. Patients and methods: Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. Results: A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. Conclusions: Results of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.

Management of hepatitis C-infected liver transplant recipients at large North American centres: changes in recent years.

Abstract:  Large (≥45 transplants per year) North American liver transplant centres were surveyed regarding management of hepatitis C virus (HCV). A total of 25/41 (59%) and 28/48 (58%) of centres responded to the surveys in 1998 and 2003, respectively, with 17 centres participating in both surveys. HCV was the most common indication for transplantation. Use of protocol liver biopsies was higher in 2003 and 60% used them to monitor HCV disease. Fewer centres reported modifying primary immunosuppression (IMS) for HCV‐positive (vs. non‐HCV) patients in 2003 (26%) vs. 1998 (56%). IMS was most frequently tacrolimus‐based, but mycophenolate mofetil use increased in 2003 (52% vs. 23% in 1998). In both years, approximately 40% treated allograft rejection differently in HCV‐positive recipients, with less use of OKT3 in 2003. Combination anti‐HCV therapy for 12 months or more was the treatment of choice and growth factor use was common (68%). HCV‐positive recipients were considered candidates for retransplantation but HCV‐specific criteria were used in decision‐making. Practice of centres changed over time with an increase in HCV transplantation and use of protocol liver biopsies, and a trend towards lesser modification of IMS in HCV‐positive recipients. We conclude that there is considerable variability in the management of HCV among transplant programs and over time.

Endoscopic ultrasound-guided biliary access versus precut papillotomy in patients with failed biliary cannulation: A retrospective study

Background and aims Precut papillotomy is widely used after failed biliary cannulation. Endoscopic ultrasound (EUS)-guided biliary access techniques are newer methods to facilitate access and therapy in failed cannulation. We evaluated the impact of EUS-guided biliary access on endoscopic retrograde cholangiopancreatography (ERCP) success and compared these techniques to precut papillotomy. Patients and methods We retrospectively compared two ERCP cohorts. One cohort consisted of biliary ERCPs (n = 1053) attempted in patients with native papillae and surgically unaltered anatomy in whom precut papillotomy and/or EUS-guided biliary access were routinely performed immediately after failed cannulation. This cohort was compared with a similar ERCP cohort (n = 1062) in which only precut papillotomy was available for failed cannulation. The following outcomes were compared: conventional cannulation success, rates of attempted advanced access techniques (precut or EUS), precut success, EUS-guided biliary access success, and ERCP failure rates. Results Although conventional cannulation success, rates of attempted advanced access technique (precut or EUS), and precut success were similar, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available (1.0 % [95 % confidence interval (CI) 0.4 - 1.6]), compared with when only precut was possible for failed access (3.6 % [95 %CI 2.5 - 4.7]; P < 0.001). Success for EUS-guided biliary access (95.1 % [95 %CI 89.7 - 100]) was significantly higher than for precut (75.3 % [95 %CI 68.2 - 82.4]; P < 0.001), and mainly due to superiority in malignant obstruction (93.5 % vs. 64 %; P < 0.001). Conclusions EUS-guided biliary access decreases the rate of therapeutic biliary ERCP failure. Our results support the use of EUS-guided biliary access to optimize single-session ERCP success. In experienced hands, these techniques appear as effective, if not more so, than precut papillotomy.

Hemostasis of Acute Gastric Variceal Bleeding

Gastric variceal hemorrhage is one of the most dreaded endoscopic emergencies. Optimal management recommendations are limited by the lack of robust evidence-based data. Although endoscopic band ligation and sclerotherapy are effective modalities for esophageal variceal bleeding, they are suboptimal therapies for fundal variceal hemorrhage. Endoscopic cyanoacrylate injection is considered a first-line treatment option, where available. The role of EUS-guided angiotherapy for gastric variceal bleeding is promising. Non-endoscopic treatment options include transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration. There is a need for prospective comparative studies among the various treatment modalities to further define optimal management algorithms for gastric variceal hemorrhage.

The Clinical Utility of Evaluating the Luminal Upper Gastrointestinal Tract During Linear Endoscopic Ultrasonography.

Background: The clinical utility of performing esophagogastroduodenoscopy (EGD) before linear endoscopic ultrasonography (L-EUS) to evaluate the luminal upper gastrointestinal (GI) tract is not well established. Goals: The study was aimed to determine the prevalence of clinically meaningful luminal abnormalities (any luminal finding requiring further evaluation with mucosal biopsy or initiation of treatment) in patients undergoing L-EUS. The study also sought to compare the ability of the gastroscope and the linear echoendoscope in identifying these lesions. Study: A prospective, multicenter cohort study enrolled patients undergoing L-EUS for nonluminal indications. All patients underwent EGD followed by L-EUS by 2 different endoscopists. The second endoscopist was blinded to the results of the initial EGD. The identification of clinically meaningful luminal lesions and quality of endoscopic visualization of the upper GI tract were measured. Results: In the cohort of 175 patients, 52 (29.7%) patients had clinically meaningful luminal findings seen in the upper GI tract. There was no significant difference in the number of clinically meaningful lesions identified on EGD and L-EUS (25.1% vs. 22.9%, P=0.39). No significant difference was found in the miss rate of clinically meaningful lesions between the 2 modalities (EGD: 4.5% vs. EUS: 6.9%, P=0.39). Conclusions: A substantial minority of patients undergoing L-EUS for nonluminal indications will have clinically meaningful luminal findings. The endoscopic evaluation of the luminal upper GI tract can be adequately achieved using the linear echoendoscope.

Indolent Primary Aortoduodenal Fistula Presenting as Iron Deficiency Anemia

A i o a i A Hispanic man with no significant past medical history was referred for esophagogastroduodenosopy (EGD) and colonoscopy because of iron deficiency anemia nd weight loss. Colonoscopy was unremarkable, but the EGD was ignificant for a 1.5-cm bulging mass with overlying exudate in the istal second portion of the duodenum (Figure A). An endoscopic ltrasound performed 2 days later revealed a 3.5-cm abdominal ortic aneurysm with compression and erosion of the duodenum ust distal to the ampulla (Figure B). The patient had no prior nown history of an abdominal aortic aneurysm. A side-viewing uodenoscope was used to confirm a normal ampulla. Computed tomography angiography showed a fusiform abominal aortic aneurysm measuring 6.3 4 4.2 cm with a .5-cm partial thrombus (Figure C). There was fibrosis around he aneurysmal sac with loss of the fat plane between the nterior aneurysmal wall (black arrow) and the third portion of he duodenum (red arrow). The patient underwent endovascular epair of the aneurysm, and the presence of an aortoduodenal stula was confirmed intraoperatively. Primary aortoduodenal fistulas (ADFs) are rare, with an incience between 0.04% and 0.07%, and occur in the absence of revious aortic aneurysm surgery. Secondary ADFs occur slightly ore commonly, with an incidence of 0.7% to 1.7%.1 Primary ADFs are usually secondary to atherosclerotic abdominal aortic aneurysms, although other causes include trauma, mycotic aneurysms, radiation, tumors, ulcers, and foreign bodies.1 The most common location of the fistula is at the third or fourth portion of the duodenum, and less likely can be found at the esophagus, proximal jejunum, ileum, or transverse colon.2 ADFs typically present with massive upper gastrointestinal bleeding, occasionally preceded by intermittent “herald” bleeding. Other findings include abdominal pain, back pain, pulsatile abdominal mass, fevers, and sepsis. Without surgical treatment, the mortality is almost 100%, and even with surgery up to 40% of patients develop complications with an overall postoperative mortality rate of 30%.3 The diagnosis of ADFs can be challenging. An initial EGD may reveal the fistula, but a negative EGD does not rule out ADF. Loss of the aneurysmal wall or fat plane between the aorta and duodenum on computed tomography scan is highly suggestive of ADF.4 This case report also shows endoscopic ultraonography may be a valuable diagnostic modality. We believe this is the first case report of an indolent primary DF diagnosed by endoscopic ultrasonography. A bulging mass n the distal duodenum should prompt further workup to rule ut an ADF. This case highlights the need for clinicians to have high index of clinical suspicion, as prompt diagnosis and ntervention are essential.