G. Curcio

Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety

BACKGROUND AND STUDY AIMnBenign biliary diseases include benign biliary stricture (BBS), lithiasis, and leaks. BBSs are usually treated with plastic stent placement; use of uncovered or partially covered metallic stents has been associated with failure related to mucosal hyperplasia. Some recently published series suggest the efficacy of fully covered self-expandable metal stents (FCSEMSs) in BBS treatment. We aimed to assess the efficacy and safety of FCSEMS in a large series of patients with BBS and a long follow-up.u200annnPATIENTS AND METHODSnProspective multicenter clinical study at three tertiary referral centers: ISMETT/UPMC Italy, Palermo, San Paolo Hospital, Milan, and the ARNAS Civico Hospital, Palermo, Italy. All consecutive patients with BBS were treated with placement of FCSEMS rather than plastic stents, as first approach (11 patients, 17.7u200a%), or as a second approach after failure of other treatments (51 patients, 82.2u200a%).nnnRESULTSnFrom January 2008 to March 2011, 62 patients (40 male) were included. Mean period of FCSEMS indwelling was 96.7 days (standard deviation [SD] 6.5 days). In 15 patients (24.2u200a%) the SEMS migrated. Resolution of BBS occurred in 56 patients (90.3u200a%), while in 6 (9.6u200a%) the treatment failed. Mean (SD) follow-up after SEMS removal was 15.9 (10) months. FCSEMS placement as first- or second-line approach showed no difference in failure. Recurrence was observed in 4u200a/56 patients (7.1u200a%); all were transplant recipients: Pu200a=u200a0.01; odds ratio (OR) 1.2, confidence interval (CI) 1.1u200a-u200a1.3.nnnCONCLUSIONSnDespite the noteworthy migration rate, FCSEMSs should be considered effective for refractory benign biliary strictures. Further studies are needed to assess their role as a first approach in the management of BBS.

Complications of endoscopic ultrasound fine needle aspiration on pancreatic cystic lesions: Final results from a large prospective multicenter study

BACKGROUNDnEndoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been reported to have a higher complication rate than that of solid lesions, but the real complication rate is unknown. Aim of the study was to identify the complication rate of endoscopic ultrasound-guided fine needle aspiration and related risk factors.nnnMETHODSnProspective multicenter study at four referral centres. Data were collected from January 2010 to July 2012, searching for all adverse events related to guided fine needle aspiration. All complications occurring up to day 90 were recorded.nnnRESULTSn298 patients (43.9% male, mean age 63.2 ± 15.4 years) underwent endoscopic ultrasound-guided needle aspiration of pancreatic cystic lesions. Mean size was 34.1 ± 9 mm. Adverse events occurred in 18 patients (6%): mild complications in 12/18 (66.6%), and moderate complications in 6/18 (33.3%). Seven were immediate, 6 early, and 5 late. All resolved with medical therapy.nnnCONCLUSIONSnEndoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been found to be associated with a higher complication rate than for solid lesions; however, the risk rate is acceptable considering the complication grade and the important diagnostic role of the technique in the management of pancreatic cystic lesions.

Diagnosis of sclerosing cholangitis in children: Blinded, comparative study of magnetic resonance versus endoscopic cholangiography

BACKGROUNDnMagnetic resonance cholangiography (MRC) has been validated as comparable to endoscopic retrograde cholangiography (ERC) for the diagnosis of sclerosing cholangitis (SC) in adult patients. In children, MRC is widely used based mainly on non-comparative studies.nnnPATIENTS AND METHODSnERCs and MRCs of seven children (median age 9, range: 7-20 years) with SC and 17 controls (median age 6, range: 2 months-20 years) with other chronic liver diseases were reviewed in a blinded, random and independent way. All patients underwent both examinations within a 6-months slot. All ERCs and 17 MRCs were performed under general anesthesia. One radiologist evaluated both ERCs and MRCs and one interventional endoscopist independently reviewed only ERCs. Reviewers did not receive any clinical information. Diagnosis of SC, established on the basis of history, laboratory data, radiological examinations and clinical course, was used as gold standard to compare ERC and MRC diagnostic accuracy.nnnRESULTSnOverall image quality was graded as very good in 57% of MRC and in 71% of ERC cases; difference was not statistically significant (P=0.24) although the probability for MRC to be diagnostic increased with patients age. Depiction of first, second and fourth-order intrahepatic bile duct was better in ERC (P=0.004, 0.02 and 0.023, respectively); depiction of the extrahepatic bile duct was comparable (P=0.052). Diagnostic accuracy of MRC and ERC was very high, without statistically significant difference (P=0.61).nnnCONCLUSIONnDespite an overall better depiction of the biliary tree by ERC, MRC is comparable for the diagnosis of SC in children. These data support MRC as the first imaging approach in children with suspected SC.

Is diagnostic accuracy of fine needle aspiration on solid pancreatic lesions aspiration-related? A multicentre randomised trial

BACKGROUNDnEndoscopic ultrasound fine needle aspiration has a central role in the diagnostic algorithm of solid pancreatic masses. Data comparing the fine needle aspiration performed with different aspiration volume and without aspiration are lacking. We compared endoscopic ultrasound fine needle aspiration performed with the 22 gauge needle with different aspiration volumes (10, 20 and 0 ml), for adequacy, diagnostic accuracy and complications.nnnMETHODSnProspective clinical study at four referral centres. Endoscopic ultrasound fine needle aspiration was performed with a 22G needle with both volume aspiration (10 and 20 cc) and without syringe, in randomly assigned sequence. The cyto-pathologist was blinded as to which aspiration was used for each specimen.nnnRESULTSn100 patients met the inclusion criteria, 88 completed the study. The masses had a mean size of 32.21±11.24 mm. Sample adequacy evaluated on site was 87.5% with 20 ml aspiration vs. 76.1% with 10 ml (p=0.051), and 45.4% without aspiration (20 ml vs. 0 ml p<0.001; 10 ml vs. 0 ml p<0.001). The diagnostic accuracy was significantly better with 20 ml than with 10 ml and 0 ml (86.2% vs. 69.0% vs. 49.4% p<0.001).nnnCONCLUSIONSnA significantly higher adequacy and accuracy were observed with the 20 ml aspiration puncture, therefore performing all passes with this volume aspiration may improve the diagnostic power of fine needle aspiration.

Pancreatic cystic lymphangioma in a 6-year-old girl, diagnosed by endoscopic ultrasound (EUS) fine needle aspiration.

clinically because they represent a spectrum of different lesions, ranging from benign to malignant. At times, the final diagnosis is made only at surgery. We report a final diagnosis of a pancreatic cystic lymphangioma, made using endoscopic ultrasound fine needle aspiration (EUSFNA) in a young girl, with cytological examination and measurement of the level of triglycerides in the intracystic fluid. A 6-year-old girl showed evidence of a pancreatic head cystic lesion on transabdominal ultrasonography. Magnetic resonance imaging (MRI) showed amultilobular cystic lesion, with an inverted C shape, around the splenomesenteric confluence (● Fig. 1). The MRI also showed a small, irregular area, which was suspected of being a solid component within the lesion. Endosonography with linear array showed a micromacrocystic lesion, 4 cm in diameter, in the pancreatic head and uncinate process (● Figs. 2, 3). No solid mass was seen. EUS-FNA with a 22 G needle was carried out to evacuate the lesion. The intracystic fluid appeared milky and viscous (● Fig. 4). Intracystic fluid analysis showed amylase/ lipase 200/1720 U/L, carcinoembryonic antigen (CEA) 0.2 ng/mL, and triglycerides 10570mg/dL. Cytology showed normal lymphocytes. The final diagnosis was pancreatic cystic lymphangioma. Abdominal ultrasound confirmed the presence of an unchanged lesion at 1 year follow-up and the patient remains asymptomatic. Cystic lymphangioma of the pancreas is an extremely rare, benign tumor of lymphatic origin [1,2]. Possible locations are in the retroperitoneum, within or outside the pancreas [3]. Histologically, it appears as a polycystic lesion, with the cysts separated by thin septa, and lined with endothelial cells. It can be difficult to distinguish this lesion from other pancreatic cystic lesions. A final diagnosis is often achievable only by histopathological examination of the resected lesion [1–3]. In cases of pancreatic cystic lymphangioma, EUS-FNA with cytological examination and measurement of the level of triglycerides in the intracystic fluid can provide a safe and accurate diagnosis [4,5]. Pancreatic cystic lymphangioma in a 6-year-old girl, diagnosed by endoscopic ultrasound (EUS) fine needle aspiration

Treatment of infected pancreatic pseudocysts using a novel, dedicated covered self-expandable metal stent (CSEMS) with an effective antimigration system

Endoscopic ultrasound (EUS)-guided treatment has become the preferred approach for managing pancreatic pseudocysts because it is associated with a lower morbidity rate compared with surgical and percutaneous approaches [1]. The disadvantages of the endoscopic approach are the need for multiple revisions because of obstruction of plastic stents, patient discomfort, and dislodgment of stents after placement of a nasocystic catheter. The most appropriate type of stent for drainage is currently a major area of interest. Covered self-expandable metal stents (CSEMSs) have recently been used for drainage of pseudocysts [2–5]. Use of CSEMSs allows creation of a largerdiameter access fistula, an increase in the final success rate, and a reduction in the time for resolution, even in complicated cysts [3–5]. One problem with using a CSEMS is the risk of stent migration. A 53-year-old man was admitted because of an episode of necrotizing acute pancreatitis. He was febrile, and a computed tomography (CT) scan showed a large pseudocyst (20cm) with solid debris, involving the head-body of the pancreas. Given the content and the large size, we planned to use a CSEMS.Using a curvilinear array echoendoscope (GF-UCT140; Olympus America Corp., Melville, New York, USA), a transgastric puncture with a 19-gauge needle (EUSN-19-T; WilsonCook Medical, Winston-Salem, North Carolina, USA) was made under EUS with Doppler guidance. A 0.035-inch wire (Jagwire, Microvasive Endoscopy, Boston Scientific, Natick, Massachusetts, USA) was positioned in the cavity, and a precut was done to create a fistula. A new CSEMS (2cm in length and 10mm in diameter) with large flares (3cm in diameter) at the extremities (Niti-S ComVi fully covered biliary stent, Taewoong Medical, Gyeonggi-do, Korea) was placed, with immediate drainage of pus (● Fig.1, ● Fig.2). The patient promptly recovered and no longer had fever. A CT scan after 10 days showed resolution of the pseudocyst. A gastroscopy conducted 3 months later showed that the CSEMS was correctly placed and patent. It was easily removed with a snare and the patient has not experienced any further problems.

PA19 OUT-OF-REACH OBSCURE BLEEDING: SINGLE-BALLOON ENTEROSCOPY FOR DIAGNOSIS AND TREATMENT OF VARICES IN HEPATICOJEJUNOSTOMY AFTER PEDIATRIC LIVER TRANSPLANT

Objective: To analyze the details of our clinical series of 15 children with eosinophilic esophagitis (EE), focusing the attention on the main clinical manifestations. and endoscopic features in order to better understand the diversity of the disease, thereby improving clinical diagnosis and treatment. Patients and methods: In the last 5 years, EE was diagnosed in 15 patients (11 males, age range 2-18 years, mean age 10.5 years). All patients underwent to an upper endoscopy with multiple biopsy specimens of the esophagus under conscious sedation. EE was defined as greater than 20 eosinophils per high power field after conventional anti-reflux treatment. All patients were tested for food allergies. Results: All studied patients were referred to our Unit after failure of antireflux therapy. The presenting symptoms were dysphagia (63%), vomiting (36%), food bolus impaction (20%), epigastric pain (18%) and chronic anemia (9%). Dysphagia and vomiting were the most common symptom, especially in the younger children, while food bolus impaction for esophageal stenosis occurred in 3 older patients. Endoscopic findings were always aspecific: normal esophagus in 6 cases (40%), low grade hyperemia in 5 (33%); high grade hyperemia in 1 (7%) and esofageal stricture in 3 (20%). The majority of allergic tests resulted negative. All patients were successively treated with swallowed corticosteroids. After 3-4 months, the corticosteroid was substituted by leukotriene receptor antagonists. Corticosteroid therapy was effective in all cases, with a rapid regression of symptoms in all children. However, after the suspension of medications, all children presented a recurrence of the disease, therefore were treated by montelukast as maintenance treatment. A mean follow-up of 2 years was based on periodical clinical evaluations and by repeated endoscopies and biopsies. Conclusions: EE is an emerging clinical entity, probably still underestimated, characterized by age-related symptoms. It has to be always ruled out in case of important clinical manifestations in the absence of a clear GERD condition, in order to avoid major esophageal complications. Montelukast offer benefit as maintenance treatment.