Christian Pesenti

Endoscopic-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses

Objective. Surgery is the traditional treatment for symptomatic pancreatic pseudocysts and abscesses, but morbidity and mortality are still too high. Minimally invasive approaches have been encouraged. The aim of this study was to evaluate the results of the endoscopic-ultrasound-guided (EUS) endoscopic transmural drainage of these pancreatic collections. Material and methods. In this retrospective review of consecutive cases from a single referral centre, cystogastrostomy and cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control by the endoscopic insertion of straight or double pigtail stents. Results. Fifty-one symptomatic patients (33 men; mean age 58 years) were submitted to 62 procedures from January 2003 to December 2005. EUS-guided drainage was successful in 48 (94%) patients. Only three patients needed surgery. There were two procedure-related complications managed clinically. During a mean follow-up of 39 weeks, recurrence due to migration or obstruction of the stent was 17.7%. All these cases were submitted to a new session of endoscopic drainage. There was no mortality. Complications were more frequent in patients with a recent episode of acute pancreatitis (38.5% versus 10%; p=0.083). The endoscopic approach was not more hazardous for abscesses in regard to complications rate (19% versus 16.6%; p>0.05). In abscesses, a nasocystic drain did not decrease the complications rate (27% versus 13%; p=0.619), but the placement of 2 stents did decrease this rate (18% versus 20%; p>0.05), although increased it in pseudocysts (40% versus 13%; p=0.185). Conclusions. Endoscopic transmural drainage is a minimally invasive, effective and safe approach in the management of pancreatic pseudocysts and abscesses.

Circumferential endoscopic resection of Barrett’s esophagus with high-grade dysplasia or early adenocarcinoma

BackgroundBarrett’s esophagus–related high-grade dysplasia or mucosal cancer can be treated by endoscopic mucosal resection (EMR), but the adjacent metaplastic epithelium remains at risk for developing further lesions. Our objective was to evaluate the results of the circumferential EMR in removing not only the neoplastic lesion but also the remaining Barrett’s epithelium.MethodsForty-one consecutive patients (mean age: 66 years) with Barrett’s esophagus were submitted to 63 EMR sessions in one single-referral endoscopic unit. All patients had high-grade dysplasia, and cancer was detected in 23 of these cases, most of them classified as T1N0 (20 patients) by endosonography. Mucosectomy after saline submucosal injection was performed for the neoplastic lesions and, if necessary, the residual Barrett’s epithelium was removed by the same technique one month later.ResultsA retrospective evaluation showed that, during a mean follow-up of 31.6 months, Barrett’s epithelium was completely replaced by squamous epithelium in 31 (75.6%) cases. There were 10 complications, all of which were managed endoscopically: 8 cases of bleeding and two perforations occurred in 9 (14.3%) patients. One patient developed an esophageal stricture. Barrett’s epithelium recurred in 10 (24.4%) patients and recurrent or metachronous early cancer was detected in 5 (12.2%), all but one of which were treated again by EMR; the fifth patient was referred to surgery. Argon plasma coagulation was used in 6 cases to treat Barrett’s epithelium, and two patients received concomitant chemoradiotherapy as adjuvant therapy.ConclusionsCircumferential EMR provides an effective endoscopic approach to the management of Barrett’s esophagus-related high-grade dysplasia and mucosal cancer. Additional studies are necessary to evaluate the long-term results.

Treatment of hepatocellular carcinoma using percutaneous radiofrequency thermoablation: Results and outcomes in 56 patients

The aim of this study was to evaluate the efficacy of and tolerance for radiofrequency thermoablation (RFTA) in patients with hepatocellular carcinoma (HCC). From March 1999 to September 2001, a total of 56 patients (46 men and 10 women) whose mean age was 67.8 years (range 51 to 76 years) underwent RFTA for 71 HCCs at our institution. RFTA was carried out in 45 patients with one lesion less than 6 cm in diameter, in seven patients with two lesions less than 4 cm in diameter each, and in four patients with three lesions less than 3 cm in diameter each. The mean diameter of the lesions was 4.1 cm (range 0.8 to 6.0 cm). The etiology of the cirrhosis was alcoholism in 31 patients, post-hepatitis C in 19 patients, post-hepatitis B in four patients, and hemochromatosis in two patients. Forty-five patients were classified as Child stage A and 11 were Child stage B. No ascites, prothrombin time >60%, and platelet count <60,000/mm3 were needed. Two types of cooled needles were used depending on the size of the lesion (a needle 15 cm in length was used for 2 or 3 cm tumors, and a cluster of needles was used for tumors larger than 4 cm). Helical computed tomography was performed 8 weeks after treatment. The main criterion for a complete response was the presence of a hypodense lesion without contrast enhancement. Mean follow-up was 14 months. Complete tumor destruction was achieved in 50 (89.2%) of 56 patients after one session and in 52 (92.8%) of 56 after two sessions. Twelve months later, a complete response was confirmed in 45 patients (80.3%), four patients had a local recurrence and new liver nodules, and three patients had died (one of bone metastasis, one of acute alcoholic hepatitis, and one of bronchial carcinoma). Thirty-nine patients (69.6%) were still in complete remission 36 months later, and a new HCC had developed in six patients. At 36 months 49 of 56 patients were alive and 39 of 56 were free of disease. Patients with HCCs that developed following viral cirrhosis had a worse prognosis than those with HCCs that occurred after alcoholic cirrhosis (2-year survival, 57.7% vs. 77.7%; P = 0.0241). It was concluded that radiofrequency ablation is an effective treatment for HCC, although the prognosis is better in patients who develop HCC after alcoholic cirrhosis compared to those in whom HCC occurs after viral cirrhosis.

Pancreatic endocrine tumors: a large single-center experience.

Objectives: Pancreatic endocrine tumors (PETs) are infrequent, which makes large experiences unlikely. Our aim was to describe a large single-center experience with PETs and the use of endoscopic ultrasound (EUS) and a cancer staging system (TNM). Methods: This study involves a retrospective analysis of 86 patients (44 men; age, 58 ± 14 years) who underwent EUS-fine needle aspiration (EUS-FNA). Immunohistochemistry was used. Lesions were classified as recommended by TNM classification. Results: Typical EUS features were well-demarcated, hypoechoic, solid, homogeneous lesions. Ninety percent had the diagnosis obtained by EUS-FNA. Twelve PETs (14%) were functioning, 8 (9.3%) were cystic, and 14 (16%) were 10 mm or smaller. Nonfunctional PETs and larger lesions were more advanced. The TNM stage was I in 24, II in 10, III in 18, and IV in 34 patients. Sixteen patients (27%) died, and 30 patients (52%) had progression/recurrence during the follow-up (34 ± 27 months). TNM stage and surgery with curative intent were related to progression. The overall 5-year survival was 60%. The mean survival time was 94 ± 12 months for stage I, 52 ± 12 months for stage III, and 54 ± 7 months for stage IV (P = 0.06). Conclusions: Nonfunctional PETs were more common and advanced. The EUS-FNA has a high accuracy for diagnosing PETs. Progression and poorer survival were associated with TNM stage.

Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts

BACKGROUND Surgery is the traditional treatment for symptomatic pancreatic pseudocysts, but the morbidity is still too high. Minimally invasive endoscopic approaches have been encouraged. AIMS To evaluate the efficacy of endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. METHODS From January, 2003 to August, 2006, 31 consecutive symptomatic patients submitted to 37 procedures at the same endoscopic unit were retrospectively analysed. Chronic and acute pancreatitis were found in, respectively, 17 (54.8%) and 10 (32.3%) cases. Bulging was present in 14 (37.8%) cases. Cystogastrostomy or cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control. By protocol, only a single plastic stent, without nasocystic drain, was used. Straight or double pigtail stents were used in, respectively, 22 (59.5%) and 15 (40.5%) procedures. RESULTS Endoscopic ultrasound-guided transmural drainage was successful in 29 (93.5%) patients. Two cases needed surgery, both due to procedure-related complications. There was no mortality related to the procedure. Twenty-four patients were followed-up longer than 4 weeks. During a mean follow-up of 12.6 months, there were six (25%) symptomatic recurrences due to stent clogging or migration, with two secondary infections. Median time for developing complications and recurrence of the collections was 3 weeks. These cases were successfully managed with new stents. Complications were more frequent in patients treated with straight stents and in those with a recent episode of acute pancreatitis. CONCLUSIONS Endoscopic transmural drainage provides an effective approach to the management of pancreatic pseudocysts.

Self-expandable metallic stents for palliative treatment of digestive cancer.

Background/Goal Self-expandable metallic stents can be used to reestablish luminal continuity in patients with malignancy of the esophagus, gastric outlet, or colon who are at high risk for surgical intervention. Data regarding their complication profiles remain incomplete. Our aim was to evaluate the feasibility and complications of endoscopic stenting in esophageal, gastroduodenal, and colonic malignancies. Study Between January 2003 and December 2005, 153 patients underwent 182 endoscopic procedures for insertion of 199 metallic stents in a single referral center. Complications were assessed retrospectively. Results The mean follow-up was 170 days. The mortality was 73.9% (113 patients), 105 cases between 1 and 60 weeks after the procedure (median survival, 17 wk), but none directly related to the stent placement. One single stent was required in 115 (75%) patients, and 37 (24.2%) cases required an overlapping stent. The procedure was unsuccessful in only 1 case of colonic obstruction. Thirty-eight (26.6%) patients developed 52 complications, of which 16 (9.4%) procedure-related complications (perforation, 5; migration, 5; obstruction, 3; misplacement, 2; and hemorrhage, 1) and 36 (21.3%) late complications (obstruction, 20; migration, 9; fistula, 6; and perforation, 1). Eight (5.6%) patients experienced more than 1 complication. Five (3.5%) cases required surgery (colon: 2 perforations, 1 fistula, and 1 obstruction; esophagus: 1 perforation). No significant difference on the complication rates was found for any site in which a metallic stent was inserted. Conclusions Endoscopic stenting for palliation of digestive cancer, despite a reasonable complication rate, is feasible in most patients. Most dysfunctions are not life-threatening and can be managed endoscopically.

Short-term results of 42 endoscopic ampullectomies: a single-center experience

Abstract Objective. Benign lesions of the major papilla are rare but raise the problem of their medical care. We studied the efficacy, safety, and histology of the endoscopic ampullectomy. Patients and methods. Forty-two endoscopic resections of the major papilla were undertaken in 23 males and 19 females of a mean age of 63. Five patients (12%) presented with a familial adenomatous polyposis. The assessment of resectability included preoperative histology, and endoscopic ultrasound (EUS) in 26 patients (62%) always showing intra-mucosal lesion. The resection was performed with a duodenoscope, using a diathermic loop with a pure current section. Results. The resection was realized in one piece for 34 patients, in 2–4 fragments for 8 patients. A plastic pancreatic stent was inserted in 26 patients (62%), a plastic biliary stent in 10 patients (24%). There were no deaths but nine complications (21%): six acute pancreatitis (four patients with a pancreatic stent, contrary to the literature), three delayed gastrointestinal bleeding. The final histological result was fibrosis and inflammatory tissue in 7 patients, low-grade dysplasia in 20 patients, high-grade dysplasia or in situ carcinoma in 10 patients, invasive adenocarcinoma in 1 patient, and somatostatinoma in 2 patients (concordance of 72% with the initial histology). The resection was complete in 39 patients (93%). Three patients had additional surgery because of positive margin of resection or bad histology criteria. The median of follow-up in 33 patients with a complete resection was of 15 months, and we did not note any recurrence in 29 patients (88%). Conclusion. Endoscopic ampullectomy is an efficient treatment for superficial lesions of the papilla, despite a significant but rarely severe morbidity. Preoperative EUS is mandatory, preoperative histology is advisable. Long-term follow-up is necessary.

Endomicroscopy in bile duct: Inflammation interferes with pCLE applied in the bile duct: A prospective study of 54 patients

Background The preoperative diagnosis of biliary stenosis is associated with low accuracy. As a consequence, probe-based confocal laser endomicroscopy (pCLE), an in-vivo histological imaging technique, was applied in the bile duct. The aim of this study was to establish whether previous inflammation of the bile duct affects confocal interpretation. The findings from pCLE were compared in two groups of patients: those in whom there had been no cholangitis nor stenting and those in whom stents had been used and subsequently retrieved or who had suffered cholangitis. Patients and methods pCLE was performed on 54 patients (mean age 66 years; 31 men, 23 women) from September 2008 to July 2011. Patients were divided in two groups: group 1: 39 patients who had not undergone a biliary procedure in the month preceding the pCLE procedure; and group 2: 15 patients who had undergone stent placement or presented with cholangitis in the month preceding the pCLE procedure. Endoscopic and pCLE data were collected prospectively. pCLE results were compared to benchmark histology (surgery, endoultrasonography, percutaneous biopsy). Patients with a benign stricture who did not undergo operation were followed for 1 year. pCLE images of the bile duct were obtained during endoscopic retrograde cholangiopancreatography procedures. pCLE images were interpreted prospectively using the Miami classification in vivo and in real time. Results In group 1, sensitivity, specificity, and accuracy were 88, 83, and 87%, respectively. In group 2, sensitivity, specificity, and accuracy were 75, 71, and 73%, respectively. Diagnostic accuracy of pCLE was lower when applied to group 2 (p < 0,001). The investigation is less reliable in bile ducts affected by inflammation from cholangitis or previous stenting. Conclusions Inflammatory lesions of the bile duct interfere with interpretation of pCLE. A refined pCLE description of inflammatory lesions should improve accuracy of pCLE in bile duct stenosis.

Feasibility of intratumoral confocal microscopy under endoscopic ultrasound guidance

The primary goal of this study was to develop descriptive image interpretation criteria and a classification of endoscopic ultrasound-confocal microscopy (EUS-CM) findings in pancreatic masses and lymph nodes through a review of prospectively obtained EUS-CM videos from proven malignant and benign cases, and to propose diagnostic criteria for predicting malignancy. The material used was a 19-G EUS-needle in which the stylet was replaced by the confocal mini-probe. The mini-probe pre-loaded in the EUS-needle was guided endosonographically in the target then the mini-probe was pushed under EUS guidance into the lesion. Eleven patients mean age 62.3 years underwent EUS for the staging of a pancreatic mass (3 cystic and 4 solid) or for the diagnosis of celiac and/or mediastinal LN (n = 4). Benign intraductal papillary mucinous neoplasm (IPMN) was characterized by the aspect of finger-like projections which correspond to the villous changes of intestinal IPMN type. In pancreatic adenocarcinomas, EUS-CM found vascular leakage with irregular vessels with leakage of fluorescein into the tumor, large dark clumps which correspond to humps of malignant cells. Inflammatory lymph nodes were characterized by the presence of diffuse small cells into a homogeneous stroma with a normal vascularization. At the opposite, EUS-CM showed in malignant lymph node glandular structures with dark cells, large dark clumps and an important neo-vascularization with huge leakage of fluorescein.

Yield of contrast-enhanced power doppler endoscopic ultrasonography and strain ratio obtained by eus-elastography in the diagnosis of focal pancreatic solid lesions

Objective: Although endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is the gold standard for diagnosing pancreatic lesions, its negative predictive value is suboptimal. Our aim was to evaluate the yield of contrast-enhanced EUS (CED-EUS) and of strain ratio EUS-elastography (SR-E-EUS) for differentiating pancreatic solid lesions. Methods: Forty-seven patients (27 men, 20 women, 70 ± 11 years) were consecutively involved in this single-center, prospective study. They were submitted to EUS, SR-E-EUS, CED-EUS with Sonovue®, and EUS-FNA. The final diagnosis was based on the histological assessment of EUS-FNA and/or surgical specimens when available, and on follow-up of at least 6 months. Results: From the 47 focal pancreatic lesions included, 13 (28%) were benign and 34 (72%) malignant. Patients with malignancy were older (70 ± 11 vs. 61 ± 8, P = 0.003), and had larger lesions (34 ± 12 mm vs. 22 ± 11 mm, P = 0.03). Malignant lesions had higher SR-E-EUS (31 ± 32 vs. 8 ± 9, P = 0.001) and more hypovascular pattern (93% vs. 33%, P < 0.001). Logistic regression determined that only hypovascularity (OR = 2.6, 95%CI: 1.5-130, P = 0.02) was independently predictive of malignancy. ROC analysis for SR-E-EUS yielded an optimal cutoff of 8 (AUC 0.91, 95%CI: 0.74-0.98) for the best power distinction for malignancy. There was no significant difference concerning sensitivity (79%, 90%, 93%) and specificity rates (85%, 75%, 67%) of EUS-FNA, SR-E-EUS, and CED-EUS, respectively. By analysis of the inconclusive EUS-FNA subset (9 patients, 19%), SR-E-EUS > 8 and hypovascularity showed sensitivity of 80% and 100%, and specificity of 67% and 67%, respectively. Conclusion: The clinical utility of CED-EUS and SR-E-EUS remains questionable. The accuracies of CED-EUS and SR-E-EUS are similar to EUS-FNA. Hypovascularity was independently predictive of malignancy. Patients with inconclusive EUS-FNA could benefit from CED-EUS due to the high sensitivity of hypovascularity for diagnosing malignancy.