Christopher J. DiMaio

Cystic Lesions of the Pancreas: Changes in the Presentation and Management of 1,424 Patients at a Single Institution over a 15-year Time Period

BACKGROUND Cystic lesions of the pancreas are being identified more frequently, and a selective approach to resection is now recommended. The aim of this study was to assess the change in presentation and management of pancreatic cystic lesions evaluated at a single institution over 15 years. STUDY DESIGN A prospectively maintained registry of patients evaluated between 1995 and 2010 for the ICD-9 diagnosis of pancreatic cyst was reviewed. The 539 patients managed from 1995 to 2005 were compared with the 885 patients managed from 2005 to 2010. RESULTS A total of 1,424 patients were evaluated, including 1,141 with follow-up >6 months. Initial management (within 6 months of first assessment) was operative in 422 patients (37%) and nonoperative in 719 patients (63%). Operative mortality in patients initially submitted to resection was 0.7% (n = 3). Median radiographic follow-up in patients initially managed nonoperatively was 28 months (range 6 to 175 months). Patients followed radiographically were more likely to have cysts that were asymptomatic (72% versus 49%, p < 0.001), smaller (1.5 versus 3 cm, p < 0.001), without solid component (94% versus 68%, p < 0.001), and without main pancreatic duct dilation (88% versus 61%, p < 0.001). Changes prompting subsequent operative treatment occurred in 47 patients (6.5%), with adenocarcinoma identified in 8 (17%) and pancreatic endocrine neoplasm in 4 (8.5%). Thus, of the 719 patients initially managed nonoperatively, invasive malignancy was identified in 12 (1.7%), with adenocarcinoma seen in 1.1%. CONCLUSION Cystic lesions of the pancreas are being identified more frequently, yet are less likely to present with concerning features of malignancy. Carefully selected patients managed nonoperatively had a risk of malignancy that was equivalent to the risk of operative mortality in those patients who initially underwent resection.

Molecular analysis of pancreatic cyst fluid: a comparative analysis with current practice of diagnosis.

The management of patients with pancreatic cysts is based on the preoperative distinction of nonmucinous and mucinous cysts in general and of benign and malignant cysts in particular. An accurate diagnosis is challenging, because endoscopic ultrasound (EUS) and cyst fluid analysis for carcinoembryonic antigen (CEA) and cytology have low sensitivity and specificity. Currently, molecular analysis is a commercially available test that promises an accurate diagnosis. The objective of the current study was to correlate a commercially provided molecular diagnosis (MDx) with a clinical consensus diagnosis (CCD) in the general categories of malignant, benign mucinous, and benign nonmucinous pancreatic cysts.

Ablation of pancreatic cystic lesions: The use of multiple endoscopic ultrasound-guided ethanol lavage sessions

Objectives: Determine the effectiveness of multiple endoscopic ultrasound-guided ethanol lavage (EUS-EL) sessions for attempted ablation of pancreatic cystic lesion (PCL). Methods: Retrospective review of patients who have undergone 2 or more EUS-EL treatments of a PCL. Eligible patients had asymptomatic, benign-appearing PCL, no previous pancreatitis, and were considered poor surgical candidates. Results: Final analysis was performed on 13 patients with suspected branch duct intraductal papillary mucinous neoplasms. The mean maximum cyst diameter at baseline and after 1 and 2 EUS-EL treatments was 20.1 ± 7.1, 17.0 ± 9.8 (P = 0.06), and 12.8 ± 9.6 mm (P = 0.0002), respectively. The mean surface area after 2 EUS-EL sessions: baseline, 5734 ± 6846 mm2; 1 EUS-EL session, 4906 ± 9240 mm2 (P = 0.52); and 2 EUS-EL sessions, 2311 ± 4093 mm2 (P = 0.008). Complete resolution of the cystic lesion was not seen by computed tomography or magnetic resonance imaging in any patient after 1 EUS-EL but occurred in 5 (38%; P = 0.02) of 13 patients after 2 EUS-EL treatments. One patient had minor abdominal pain 1 day after the first EUS-EL session and 2 days after the second session. Conclusions: Compared with only 1 EUS-EL, 2 EUS-EL treatment results in a significantly greater decrease in the size and surface area of PCL and is associated with a significantly higher rate of image-defined cyst resolution.

EUS-guided fiducial placement for image-guided radiation therapy in GI malignancies by using a 22-gauge needle (with videos )

BACKGROUND Image-guided radiation therapy (IGRT) is dependent on the presence of fiducial markers for target localization and tracking. EUS-guided placement of fiducial markers with a 19-gauge needle has been reported. However, the size and stiffness of the 19-gauge needle may compromise the safety and ease of fiducial placement. OBJECTIVE The aim of this study was to evaluate the safety and feasibility of EUS-guided placement of thin flexible gold coil fiducials by using a 22-gauge needle. DESIGN Retrospective study. SETTING Memorial Sloan-Kettering Cancer Center, between December 2008 and November 2009. PATIENTS A total of 30 patients with GI malignancies of the mediastinum and upper abdomen who were to undergo IGRT. INTERVENTIONS EUS evaluation with a curvilinear-array echoendoscope was performed. The target lesion was identified, a 22-gauge needle preloaded with a gold coil fiducial was inserted into the lesion, and the fiducial was deployed under EUS guidance. MAIN OUTCOME MEASUREMENTS Technical success was defined as the ability to place fiducials in the desired location. Immediate and delayed complications were also noted. RESULTS A total of 69 fiducials were placed in 12 different sites in the mediastinum and upper abdomen. Technical success was achieved in 29 out of 30 cases (97%). No intraprocedural complications were encountered. One patient developed a fever and abnormal liver function tests 12 hours after fiducial placement. LIMITATIONS Retrospective design, small case series. CONCLUSIONS EUS-guided placement of thin flexible gold coil fiducials by using a 22-gauge needle is both safe and feasible for upper GI malignancies.

Carcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction

BACKGROUND Endoscopically inserted self-expandable metal stents (SEMSs) are used to palliate malignant gastric outlet obstruction (GOO). Peritoneal disease is considered a relative contraindication to SEMS placement given the risk of multifocal obstruction. OBJECTIVE To evaluate the success of SEMSs placed in patients with GOO with carcinomatosis. DESIGN Retrospective review of patients who underwent SEMS placement for malignant GOO. SETTING Large, urban cancer center. PATIENTS A total of 215 patients who were scheduled for SEMS placement for GOO. INTERVENTIONS SEMS placement. MAIN OUTCOME MEASUREMENTS Technical success, clinical success, early and late SEMS failure, and complications. RESULTS Technical success was achieved in 192 of 201 patients (95.5%). Of the 9 patients who did not achieve technical success, 6 had carcinomatosis. Among the 116 patients (60%) with carcinomatosis, clinical success was achieved 94 of them (81%). Of these 94 patients, 17 (18%) required reinterventions: 4 for early SEMS failure and 13 for late SEMS failure. Among the 76 patients (40%) without carcinomatosis, clinical success was achieved in 64 of them (84%). Of these 64 patients, 17 (27%) required reinterventions: 4 for early SEMS failure and 13 for late SEMS failure. Complication rates were similar for both groups. LIMITATIONS This was a retrospective review with experienced clinicians selecting patients whom they thought would benefit from SEMS placement. CONCLUSIONS This is the first study to evaluate the effect of carcinomatosis on the technical and clinical success of SEMSs in the palliation of malignant GOO. We found clinical outcomes comparable to those without peritoneal disease. Carcinomatosis should not be considered a contraindication to SEMS placement in selected patients with malignant GOO.

Colonoscopy core curriculum

n d S i t i v f t a b This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and for trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of colonoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of colonoscopy.

Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract

BACKGROUND EUS-FNA often fails to make a definitive diagnosis in the evaluation of subepithelial lesions. The addition of jumbo biopsy forceps has the potential to improve diagnostic yield, but published series are limited. OBJECTIVE To assess the likelihood of definitive diagnosis for subepithelial lesions by using jumbo biopsy forceps during EUS examination. DESIGN Pooled retrospective analysis. SETTING 6 tertiary referral centers. PATIENTS All patients having undergone EUS examination for a subepithelial lesion in which jumbo biopsy forceps were used for tissue acquisition. MAIN OUTCOME MEASUREMENTS Diagnostic yield of jumbo biopsy forceps use, complication rates, and comparison of diagnostic yield with that of EUS-FNA. RESULTS A total of 129 patients underwent EUS with jumbo biopsy forceps; 31 patients (24%) had simultaneous EUS-FNA. The lesion locations were stomach (n = 98), esophagus (n = 14), duodenum (n = 11), colon (n = 5), and jejunum (n = 1). The average lesion size was 14.9 mm ± 9.3 mm. Overall, definitive diagnosis was obtained in 87 of 129 patients (67.4%) by using either method. A definitive diagnosis was provided by jumbo biopsy forceps use in 76 of 129 patients (58.9%) and by FNA in 14 of 31 patients (45.1%) (P = .175). The results in third-layer lesions were definitive with jumbo biopsy forceps in 56 of 86 lesions (65.1%) and with FNA in 6 of 16 lesions (37.5%) (P = .047). For fourth-layer lesions, the results with jumbo biopsy forceps were definitive in 10 of 25 (40.0%) and with FNA in 8 of 14 (57.1%) (P = .330). Forty-five of 129 patients (34.9%) experienced significant bleeding after biopsy with jumbo forceps and required some form of endoscopic hemostasis. LIMITATIONS Retrospective study. CONCLUSIONS Jumbo forceps are a useful tool for the definitive diagnosis of subepithelial lesions. The greatest benefit appears to be with third-layer (submucosal) lesions. The risk of bleeding is significant.

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

A Large Multicenter Experience With Endoscopic Suturing for Management of Gastrointestinal Defects and Stent Anchorage in 122 Patients: A Retrospective Review.

Goals:To describe a multicenter experience using an endoscopic suturing device for management of gastrointestinal (GI) defects and stent anchorage. Background:Endoscopic closure of GI defects including perforations, fistulas, and anastomotic leaks as well as stent anchorage has improved with technological advances. An endoscopic suturing device (OverStitch; Apollo Endosurgery Inc.) has been used. Study:Retrospective study of consecutive patients who underwent endoscopic suturing for management of GI defects and/or stent anchorage were enrolled between March 2012 and January 2014 at multiple academic medical centers. Data regarding demographic information and outcomes including long-term success were collected. Results:One hundred and twenty-two patients (mean age, 52.6 y; 64.2% females) underwent endoscopic suturing at 8 centers for stent anchorage (n=47; 38.5%), fistulas (n=40; 32.7%), leaks (n=15; 12.3%), and perforations (n=20; 16.4%). A total of 44.2% underwent prior therapy and 97.5% achieved technical success. Immediate clinical success was achieved in 79.5%. Long-term clinical success was noted in 78.8% with mean follow-up of 68 days. Clinical success was 91.4% in stent anchorage, 93% in perforations, 80% in fistulas, but only 27% in anastomotic leak closure. Conclusions:Endoscopic suturing for management of GI defects and stent anchoring is safe and efficacious. Stent migration after stent anchoring was reduced compared with published data. Long-term success without further intervention was achieved in the majority of patients. The role of endoscopic suturing for repair of anastomotic leaks remains unclear given limited success in this retrospective study.

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.