Francesco Auriemma

Intrabiliary resection of metastasis originating from colorectal carcinoma during direct peroral cholangioscopy: a new tool for biliary palliation

Intrabiliary growth of a liver metastasis originating from colorectal carcinoma is a rare manifestation of metastatic liver carcinoma, with only a few cases reported in the literature [1–3]. Radiological characteristics of the “classic” liver metastases are well established, and generally preoperative biopsy to plan a proper surgical strategy is not required. However, the radiological features of intrabiliary liver metastasis may not be distinctive, leading to possible misdiagnosis. We present the case of an 83-year-old woman who was referred to our unit because of jaundice. The medical history reported left hemicolectomy for cancer (pT3N0) 15 years earlier and hepatic segmentectomy for metastatic nodule 5 years earlier. Computed tomography and magnetic resonance imaging scans showed dilation of the common bile duct and intrahepatic bile ducts, with an intraductal nodule at the hepatic hilum (▶Fig. 1). Carcinoembryonic antigen and α-fetoprotein levels were normal. Endoscopic retrograde cholangiopancreatography showed a dilated biliary duct (14mm) with a “negative” image of about 20mm at the bifurcation. After sphincterotomy and papilloplasty up to 12mm, direct peroral cholangioscopy (POC) was performed using a slim scope (8.5mm diameter, EG 530FP; Fujifilm, Tokyo, Japan). A polypoid mass with irregular vascular pattern, highly suggestive of malignancy, was observed at the hepatic hilum (▶Fig. 2 a). Endoscopic resection of the lesion, under direct visualization, with a hot snare (15mm, Captivator II; Boston Scientific Corp., Marlborough, Massachusetts, USA) was performed, thus avoiding the need for biliary stent placement (▶Fig. 2b, ▶Video1). Histology revealed a metastasis of colorectal carcinoma (▶Fig. 3). The patient remained free of symptoms with normal bilirubin level for 12 months. To our knowledge this is the first case of an intrabiliary endoscopic resection performed under direct visualization. The POC is an advanced technique for intraluminal visual inspection and for therapeutic intervention of the biliary ducts [4], and shows potential as a promising approach in the diagnosis and treatment of a subgroup of patients with biliary obstruction secondary to intraductal masses.

Intrabiliary argon plasma coagulation hemostasis by direct cholangioscopy for a tricky post-ERCP bleeding

An 80-year-old man was admitted to the emergency department with fever, jaundice, and abdominal pain due to common bile duct (CBD) lithiasis. His past medical history revealed chronic renal failure and atrial fibrillation, which was treated with warfarin. Therapy with antibiotics and phytomenadione was promptly started, and international normalized ratio values returned to normal. Cholangiography showed the CBD dilated up to 18mm and multiple large stones. Sphincterotomy was performed, followed by papillary pneumatic dilation up to 15mm and stone extraction, with no residual filling defect at cholangiography. E-Videos

Endoscopic ultrasound-elastography (strain ratio) in the diagnosis of solid pancreatic lesions: A prospective cohort study

Background and Objectives: Endoscopic ultrasound (EUS) elastography is a noninvasive ultrasound technique that measures the stiffness of tissues. Both a qualitative score and a quantitative method (strain ratio [SR]) can be used to study the hardness of solid pancreatic lesions (SPLs). This single-center prospective cohort study aimed to evaluate the efficacy of the combination of EUS elastography and SR for the diagnosis of SPL using the elastography software on the new Olympus echo-processor EU-ME2. Methods: Two different areas were selected: area A included the tumor; area B was placed in a soft peri-tumoral normal (parenchymal SR [pSR]) and in the gastrointestinal wall (wall SR [wSR]). The quantitative score of elastography was calculated by the SR method (area B/area A). Elasticity measurements were performed 3 times in each procedure. Means of pSR and of wSR were calculated and used as final results for each patient. Final diagnosis was made on the basis of EUS-guided fine needle aspiration, surgical specimens, or follow-up of at least 6 months. Results: Study population included 100 patients and a total of 102 SPLs. Mean lesion (standard deviation) size was 27.1 mm (12.4). The final diagnosis classified SPL into adenocarcinoma (ADC, n = 69) or benign lesions (n = 33). Benign lesion group included 19 neuroendocrine tumors. ROC analysis identified a cutoff of SR of 9.1 as the best value for the detection of malignancy. Sensitivity, Specificity, positive predictive value, negative predictive value, and accuracy with their cutoff value for malignancy are shown in the full article. Univariate logistic regression analysis showed that both pSR and wSR were significant discriminators for ADC and benign SPL. The overall area under the characteristic curve was 88.6% (81.2%–96.0%), indicating good ability in discriminating between cancers and benign lesions. The major limitation of this study is the low number of benign masses, but these preliminary data showed the feasibility of the SR calculated with the Olympus EU-ME2 echo-processor and the higher SR values in ADC. Conclusions: EUS-elastography may be helpful in the diagnosis of SPLs, especially in the identification of those suspected for ADC. Further studies are needed to assess its diagnostic accuracy and reproducibility.