Dong Hui Cho

Usefulness of argon plasma coagulation ablation subsequent to endoscopic snare papillectomy for ampullary adenoma

Endoscopic snare papillectomy (ESP) is an effective treatment for ampullary adenoma. Argon plasma coagulation (APC) is widely used as an additional method to control bleeding or ablate the residual tumor. However, the efficacy of this procedure has not yet been fully evaluated. This study aimed to evaluate the usefulness of APC as an additional method to ESP.

Comparison between groove carcinoma and groove pancreatitis

BACKGROUND/OBJECTIVES The pancreatoduodenal groove (anatomical groove) is a potential space bordered by the head of the pancreas, duodenum, and common bile duct. Discerning between groove carcinoma (GC) and groove pancreatitis (GP) is often difficult, but clinically important. We retrospectively analyzed and compared the findings of computed tomography (CT), laboratory tests, and endoscopic ultrasound-fine needle aspiration (EUS-FNA) for GC and GP. METHODS GC (n = 36) and GP (n = 44) patients at Asan Medical Center from January 1, 2000, to May 31, 2017 were retrospectively reviewed. MDCT findings, baseline characteristics, laboratory test results, and EUS and EUS-FNA findings of GC and GP patients were compared. RESULTS CT showed no significant difference in groove enhancement between the groups. Mass-like lesions, cystic groove lesions, and calcification were observed in 86.1% and 15.9%, 38.9% and 75%, and 2.8% and 29.5% of GC and GP patients, respectively. Patients were tested for total bilirubin (GC: 2.0 vs. GP: 0.6 mg/dL), cancer antigen 19-9 (CA19-9) (GC: 76 vs. GP: 12.5 U/mL), and carcinoembryonic antigen (GC: 2.4 vs. GP: 2 ng/mL). Three GP patients died, and one GP patient was diagnosed with GC. However, among 30 GC patients with at least 1-year follow-up, 20 died. In multivariate logistic regression, CA19-9, and mass-like lesion on multidetector CT (MDCT) were discriminating factors between GC and GP. Among 23 (10 GC, 13 GP) patients who underwent EUS-FNA, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy of EUS-FNA were 90%, 100%, 100%, 92.86%, and 95.65%, respectively. CONCLUSIONS Several MDCT and laboratory findings favor GC over GP. EUS-FNA should be considered in patients with elevated CA19-9 levels and mass-like lesions on MDCT.

Trans-sigmoidal endoscopic ultrasonography-guided fine needle biopsy of a pancreas allograft for the diagnosis of post-transplant lymphoproliferative disorder

Biopsy of pancreas allografts has a critical role in the evaluation of pancreas allograft dysfunction [1]. However, percutaneous ultrasound or computed tomography (CT)-guided biopsy of a pancreas allograft in the pelvis may not be feasible in some cases. Pelvic lesions are easily imaged endosonographically from the rectum or distal sigmoid colon. Although transrectal endoscopic ultrasonography (EUS)-guided biopsy or drainage for pelvic lesions has been demonstrated to be feasible and safe [2, 3], there have been no reports of lower gastrointestinal EUSguided fine needle biopsy (FNB) of a pancreas allograft in the pelvis owing to the unique anatomic configuration of the post-transplant anatomy [4]. A 47-year-old man underwent simultaneous pancreas and kidney transplantation 10 years ago for insulin-dependent diabetes mellitus and end-stage renal disease due to diabetic nephropathy. The graft duodenum had been anastomosed to the proximal jejunum to allow for enteric exocrine drainage. The patient presented to us with right lower abdominal pain and elevated levels of amylase and lipase. His abdominopelvic CT scan showed swelling of the pancreas allograft with pancreatic duct dilatation and peripancreatic infiltration (▶Fig. 1). Given this picture, histologic evaluation of the pancreas allograft was mandatory, but the direction of its body and tail, placed towards the right pelvis, was not suitable for percutaneous access. Therefore, we decided to perform a trans-sigmoidal EUS-guided FNB. The procedure was performed after the patient had undergone bowel preparation. A linear echoendoscope was rotated counter-clockwise in the distal sigmoid colon, and the pancreas allograft was visualized in the right pelvis. Trans-sigmoidal EUS-FNB was performed with a 22-gauge needle (ProCore Needle; COOK Medical) (▶Fig. 2; ▶Video1) using the stylet slow-pull technique for a pancreas allograft. A total of four needle passes were made and no procedure-related adverse events were seen. The biopsy revealed monomorphic-type post-transplant lymphoproliferative disorder consistent with Burkitt lymphoma based on histological, immunohistochemical, and fluorescence in situ hybridization (FISH) analysis (▶Fig. 3). After receiving the first cycle of hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (Hyper-CVAD), the patient’s lower abdominal pain and elevated pancreatic enzymes were improved.