Fabrice Caillol

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.

A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy

BACKGROUND AND STUDY AIMS The differential diagnosis of solitary pancreatic cystic lesions is frequently difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a new technology enabling real-time imaging of the internal structure of such cysts. The aim of this pilot study was to identify and validate new diagnostic criteria on nCLE for pancreatic cystic lesions. PATIENTS AND METHODS A total of 31 patients with a solitary pancreatic cystic lesion of unknown diagnosis were prospectively included at three centers. EUS-FNA was combined with nCLE. The final diagnosis was based on either a stringent gold standard (surgical specimen and/or positive cytopathology) or a committee consensus. Six nonblinded investigators reviewed nCLE sequences from patients with the most stringent final diagnosis, and identified a single feature that was only present in serous cystadenoma (SCA). The findings were correlated with the pathology of archived specimens. After a training session, four blinded independent observers reviewed a separate independent video set, and the yield and interobserver agreement for the criterion were assessed. RESULTS A superficial vascular network pattern visualized on nCLE was identified as the criterion. It corresponded on pathological specimen to a dense and subepithelial capillary vascularization only seen in SCA. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of this sign for the diagnosis of SCA were 87 %, 69 %, 100 %, 100 %, and 82 %, respectively. Interobserver agreement was substantial (κ = 0.77). CONCLUSION This new nCLE criterion seems highly specific for the diagnosis of SCA. The visualization of this criterion could have a direct impact on the management of patients by avoiding unnecessary surgery or follow-up.Clinicaltrials.gov NCT01563133.

EUS-FNA predicts 5-year survival in pancreatic endocrine tumors.

BACKGROUND Pancreatic endocrine tumors (PETs) differ in clinical behavior and prognosis. Determination of malignant potential through specimens obtained by EUS-FNA can help in the management of these patients. OBJECTIVE To determine the value of EUS-FNA for diagnosing PETs and for classifying their underlying malignant potential based on the World Health Organization (WHO) classification. DESIGN Single-center, retrospective, cohort study. SETTING Tertiary referral hospital. PATIENTS This study involved 86 consecutive patients (44 men, mean age 58 +/- 14 years) who had been diagnosed with PETs and submitted to EUS-FNA from January 1999 to August 2008. INTERVENTION EUS-FNA of a pancreatic mass and/or a metastasis site. Immunohistochemistry on microbiopsies or on monolayer cytology was routinely used. The lesions were classified as recommended by the WHO. MAIN OUTCOME MEASUREMENTS EUS-FNA sensitivity and 5-year survival rate. RESULTS Overall, in 90% (77 of 86) of patients in this study, PET was diagnosed with EUS-FNA. The sensitivity did not vary with tumor size, type, location, or the presence of hormonal secretion. Of 86 patients, 30 (35%) were submitted to surgical resection. The kappa correlation index between the WHO classification obtained by EUS-FNA and by surgery was 0.38 (P = .003). Major discrepancies were found in the group of patients diagnosed with endocrine tumor of uncertain behavior by EUS-FNA, because 72% turned out to have well-differentiated endocrine carcinoma. Sixteen patients (27%) died during a mean follow-up period of 34 +/- 27 months. The 5-year survival rates were 100% for endocrine tumors, 68% for well-differentiated endocrine carcinomas, and 30% for poorly differentiated endocrine carcinomas (P = .008, log-rank test). LIMITATIONS Retrospective design, selection bias, and small sample size. CONCLUSIONS This largest single-center experience to date demonstrated the accuracy of EUS-FNA in diagnosing and determining the malignant behavior of PETs. EUS-FNA findings predict 5-year survival in patients with PETs.

Validation of the diagnostic accuracy of probe-based confocal laser endomicroscopy for the characterization of indeterminate biliary strictures: results of a prospective multicenter international study

BACKGROUND Characterization of indeterminate biliary strictures remains problematic. Tissue sampling is the criterion standard for confirming malignancy but has low sensitivity. Probe-based confocal laser endomicroscopy (pCLE) showed excellent sensitivity in a registry; however, it has not been validated in a prospective study. OBJECTIVE To prospectively validate pCLE in real time during ERCP for indeterminate biliary strictures. DESIGN Prospective, international, multicenter study. SETTING Six academic centers. PATIENTS A total of 136 patients with indeterminate biliary strictures. INTERVENTIONS Investigators provided a presumptive diagnosis based on the patient history, ERCP impression, and pCLE during the procedure before and after tissue sampling results were available. A presumptive diagnosis also was made separately by a blinded investigator during ERCP and after tissue sampling to estimate care without pCLE. Follow-up was at least 6 months. MAIN OUTCOME MEASUREMENTS Accuracy, sensitivity, and specificity during ERCP alone, ERCP with pCLE, and ERCP with pCLE and tissue sampling. RESULTS A total of 112 patients were evaluated (71 with malignant lesions). Tissue sampling alone was 56% sensitive, 100% specific, and 72% (95% confidence interval [CI], 63%-80%) accurate. pCLE with ERCP was 89% sensitive, 71% specific, and 82% (95% CI, 74%-89%) accurate. After tissue sampling returned, strictures could be characterized with 88% (95% CI, 81%-94%) accuracy. LIMITATIONS No randomization of care maps. pCLE not blinded. CONCLUSION pCLE provided a more accurate and sensitive diagnosis of cholangiocarcinoma compared with tissue sampling alone. Incorporation of pCLE into the diagnostic armamentarium of patients with indeterminate biliary strictures may allow for a more accurate assessment, potentially reducing delays in diagnosis and costly repeat testing. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01392274.).

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.

Use of probe-based confocal laser endomicroscopy (pCLE) in gastrointestinal applications. A consensus report based on clinical evidence

Background Probe-based confocal laser endomicroscopy (pCLE) provides microscopic imaging during an endoscopic procedure. Its introduction as a standard modality in gastroenterology has brought significant progress in management strategies, affecting many aspects of clinical care and requiring standardisation of practice and training. Objective This study aimed to provide guidance on the standardisation of its practice and training in Barrett’s oesophagus, biliary strictures, colorectal lesions and inflammatory bowel diseases. Methods Initial statements were developed by five group leaders, based on the available clinical evidence. These statements were then voted and edited by the 26 participants, using a modified Delphi approach. After two rounds of votes, statements were validated if the threshold of agreement was higher than 75%. Results Twenty-six experts participated and, among a total of 77 statements, 61 were adopted (79%) and 16 were rejected (21%). The adoption of each statement was justified by the grade of evidence. Conclusion pCLE should be used to enhance the diagnostic arsenal in the evaluation of these indications, by providing microscopic information which improves the diagnostic performance of the physician. In order actually to implement this technology in the clinical routine, and to ensure good practice, standardised initial and continuing institutional training programmes should be established.

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.

Cystic Pancreatic Endocrine Tumors An Endoscopic Ultrasound-guided Fine-Needle Aspiration Biopsy Study With Histologic Correlation

Cystic pancreatic endocrine tumors (PETs) are rare neoplasms with a preoperative diagnostic challenge. The aim of this study was to evaluate the preoperative diagnostic strategy for these tumors and to assess the clinical and pathologic characteristics.