Georgios Mavrogenis

25-gauge histology needle versus 22-gauge cytology needle in endoscopic ultrasonography-guided sampling of pancreatic lesions and lymphadenopathy.

Background and study aims: A new 25-gauge (G) endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) device (EchoTip ProCore; Cook Medical, Bloomington, Indiana, USA) has been developed, which features a hollowed-out reverse bevel to trap core samples. However, data on the differences between the diagnostic yield of the 25G EchoTip ProCore and that of a 22G standard needle are limited. Patients and methods: This pilot study included 27 patients referred during an 11-month period for EUS-FNA of pancreatic masses and enlarged lymph nodes adjacent to the upper gastrointestinal tract. Each lesion was punctured once by both a 25G EchoTip ProCore needle and a 22G standard needle (EchoTip; Cook Medical) with capillary sampling. Blinded histocytologic analyses were conducted. The final diagnosis was based on FNA findings of malignant cells, pathologic analysis of the surgical specimen, and/or radiologic and clinical follow-up of at least 7 months. Results: A total of 28 EUS-FNA procedures targeting masses of the pancreas (n = 19) and lymph nodes (n = 9) were performed. No complications were encountered. Single-pass sensitivity rates for pancreatic and lymph node malignancy were equal for the needle types: 89.5 % (95 %CI 66.82 – 98.39) and 66 % (95 %CI 24.1 – 94), respectively. There were no significant differences between the needles in terms of EUS visualization (P = 0.125), amount of blood contamination (P = 0.705), macroscopic quantity of the material (P = 0.858), quality of the cytology (P = 0.438), and adequacy and accuracy of the cell block material (P = 0.220). Conclusions: Both needles were safe and successful in terms of a high diagnostic yield, with similar histocytologic results. The results of this study were presented at Digestive Disease Week (DDW) 2014, Chicago, Illinois. This trial was registered at ClinicalTrials.gov (B027201316271).

KID Project: an internet-based digital video atlas of capsule endoscopy for research purposes

Background and aims  Capsule endoscopy (CE) has revolutionized small-bowel (SB) investigation. Computational methods can enhance diagnostic yield (DY); however, incorporating machine learning algorithms (MLAs) into CE reading is difficult as large amounts of image annotations are required for training. Current databases lack graphic annotations of pathologies and cannot be used. A novel database, KID, aims to provide a reference for research and development of medical decision support systems (MDSS) for CE. Methods  Open-source software was used for the KID database. Clinicians contribute anonymized, annotated CE images and videos. Graphic annotations are supported by an open-access annotation tool (Ratsnake). We detail an experiment based on the KID database, examining differences in SB lesion measurement between human readers and a MLA. The Jaccard Index (JI) was used to evaluate similarity between annotations by the MLA and human readers. Results  The MLA performed best in measuring lymphangiectasias with a JI of 81 ± 6 %. The other lesion types were: angioectasias (JI 64 ± 11 %), aphthae (JI 64 ± 8 %), chylous cysts (JI 70 ± 14 %), polypoid lesions (JI 75 ± 21 %), and ulcers (JI 56 ± 9 %). Conclusion  MLA can perform as well as human readers in the measurement of SB angioectasias in white light (WL). Automated lesion measurement is therefore feasible. KID is currently the only open-source CE database developed specifically to aid development of MDSS. Our experiment demonstrates this potential.

Technological review on endoscopic submucosal dissection: available equipment, recent developments and emerging techniques

Abstract Endoscopic submucosal dissection (ESD) is widely practiced in Japan and the Eastern World and is rapidly expanding in western countries for the management of early malignancies of the upper and lower gastrointestinal tube. In addition, novel therapeutic applications deriving from ESD have emerged including the treatment of achalasia, of submucosal tumors, of diverticula, of strictures and of reflux disease. An ESD procedure necessitates not only skills and specific training, but also familiarization with a vast spectrum of devices (endoscopes, high-frequency generators and their settings, endoknives, hoods, irrigation devices) and techniques (such as countertraction, artificial ulcer closure), that render the procedure faster, more efficient and safer. This technological article gives an overview on current and novel equipment for an ESD and associated techniques.

Focal autoimmune pancreatitis: role of “modern” endoscopic ultrasound endoscopy?

We read with interest the review by Maillette de Buy Wenniger et al. on the immunoglobulin-G4-associated disease of the pancreas and biliary tree. The authors illustrated in detail the multidisciplinary diagnostic approach of autoimmune pancreatitis (AIP), which combines histology, imaging, serology, other organ (nonpancreatic) involvement, and response to steroid therapy (Mayo HISORt criteria). We would like to comment on the role of new endoscopic ultrasound (EUS) techniques in the diagnosis of focal AIP. Due to the absence of pathognomonic features on standard imaging studies, tissue sampling is generally necessary to firmly establish the diagnosis. However, is tissue sampling sufficient to both exclude malignancy and be specific enough for a diagnosis of AIP? EUS-guided fine-needle aspiration (FNA) has an accuracy of between 85 % and 95 % for cancer diagnosis, with still a significant rate of false-negative results, which indicates the need for repeat EUS – FNA. However, negative cytology or histology obtained by EUS – FNA does not exclude AIP. In order to further investigate these subgroups of patients, the endoscopist possesses two promising imaging tools: real-time EUS elastography of the pancreas and/or contrast-enhanced EUS. Of course, these modalities need state-of-the-art ultrasound systems, and new technology comes with a price tag. Elastographic imaging of pancreatic tumors is usually homogeneous and largely dominated by blue (stiff) areas or strands, with normal elastographic patterns in the remaining parenchyma. Conversely, patients with focal AIP present with a unique pattern of small spotted mainly blue color signals that are evenly spread. In addition, when targeted masses are unclear on fundamental B-mode EUS imaging, elastography may be useful to find the targeted area. Contrast-enhanced EUS using Doppler mode has also proved useful in the discrimination of pancreatic cancer from focal chronic pancreatitis.Focal AIP presents a net-like hypervascularization pattern after contrast agent injection. Conversely, color and power Doppler demonstrate a relatively hypovascular pattern in pancreatic adenocarcinoma compared with the remaining pancreas parenchyma, with a sensitivity and specificity comparable to cytopathology. We believe therefore that EUS elastography and contrast-enhanced EUS alone or in combination are promising tools in the diagnostic approach of focal AIP. Although, they may be considered as “toys” by some experts, it seems that in the near future their use might be integrated in the diagnostic algorithms of AIP.

Submucosal pocket-assisted enucleation of gastric submucosal lesions

Identifying and resecting gastric submucosal lesions through submucosal tunneling is not always easy, because of difficulties in orientation or a lack of sufficient working space. This article presents the resection of two gastric lipomas with a modified pocket-creation method (Fig. 1), initially scheduled for endoscopic submucosal dissection (ESD) of epithelial lesions [1]. A 63-year-old male was referred for endoscopic resection of two submucosal lesions of the antrum for both diagnostic and therapeutic purposes (Fig. 2). The procedure was undertaken under general anesthesia. Both lesions were resected as follows. A mixture of indigo carmine and hydroxyethyl starch was injected and a 2-cm horizontal mucosal incision was made at the proximal border of the lesion with a tip-cutting knife (Splash-M Knife, Pentax, Japan). Then, a submucosal pocket, 2-3 cm in depth, was created using Endocut Q, Effect 3 (VIO3, ERBE, Germany). The tumors were progressively enucleated through the submucosal pocket by means of standard ESD techniques. At the end of the procedure, both submucosal entrances were closed with hemostatic clips. The patient received doubledose proton pump inhibitor treatment; he was discharged 24 h later and had an uneventful recovery. Both lesions had histology features of benign lipomas. In conclusion, this image illustrates a modified ESDderived technique for the resection of gastric submucosal tumors. Enucleation of the lesion is achieved through a submucosal pocket that offers more space and better orientation compared to the standard tunneling technique,

Clip and snare countertraction technique for rectal submucosal dissection.

Α 62-year-old woman was scheduled for screening colonoscopy. Endoscopy revealed a flat erythematous zone of 2 × 2 cm of the distal rectum with a 2-mm expansion into the anal canal (Fig. 1). Biopsies were consistent with an adenomatous lesion with low-grade dysplasia. In view of the location of the lesion, we decided to resect it by means of endoscopic submucosal dissection. The lesion was lifted with a mixture of 500 mL of 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection (Voluven®, Fresenius Kabi Hellas A.E.), 2 mL of indigo carmine, 1 mg of adrenaline, and 75 mg of ropivacaine. After a circumferential incision and trimming of the periphery, a clip (EZ Clip, Olympus) was placed on the mucosal flap of the anal side of the lesion. A polypectomy snare was then looped over the tip of the endoscope and released over the deployed clip. The snare secured the proximal part of the clip and the handle was fixed in the closed position. Thus, pushing or pulling the catheter of the snare applied controllable back and forward countertraction. At the end of the procedure, the snare was retracted to retrieve the resected specimen. Endoscopists should be aware of this low-cost and readily accessible countertraction technique that allows bidirectional traction, the possibility of snare removal when no further countertraction is needed, and finally retrieval of the resected specimen. Although initially described in a case series of gastric endoscopic submucosal dissection, the clip and snare technique proved its efficacy in shortening the overall duration of the procedure in a recent comparative study from Japan including 17 colorectal lesions [1,2].

Closure of large post-endoscopic submucosal dissection defects with lateral mucosal incisions and clips

With the introduction of endoscopic submucosal dissection (ESD) techniques, complex lesions can now be resected. Artificial ulcers may be closed or left open according to endoscopist’s preference. However, closure of large defects may accelerate healing and thus diminish the risk of late bleeding [1]. Clipping of large defects in a sequential zipper fashion can be cumbersome or even impossible. Alternative options include the use of a double-channel endoscope with an endoloop and clips, a figure of 8-shaped stainless clip in combination with clips, a nylon-string loop attached to a clip, over-thescope clips and the overstitch endoscopic suturing device [2,3]. Nevertheless, these techniques need additional equipment and increase the overall cost. We recently had the experience of an 80-year-old patient under low-dose aspirin with a history of chronic renal failure, who underwent ESD of a 3x3 cm early gastric cancer (carcinoma in situ) (Fig. 1). The post-ESD defect was too large for clipping in a zipper fashion. We decided to apply a technique introduced by Otake et al [3], for the closure of colonic mucosal defects. Two small incisions were made in each side of the defect. These mucosal holes served as a grip for traction. With the help of two clips (Hemoclip, Life Partners, France), the oral border of the defect was dragged and then attached to the opposite border. Then, complementary closure of the residual defect was easily achieved with 7 additional clips (EZ Clips, Olympus, Greece). The patient was discharged after 24 h, and did not present any complication. References

A large polyp in the rectum: not always an epithelial lesion

Dear Editor:Solitaryextramedullaryplasmocytoma(SEP)isanexceeding-ly rare entity accounting for less than 5 % of all plasma celldyscrasias,suchasmonoclonalgammopathyofundeterminedsignificance (MGUS), multiple myeloma (MM), solitaryplasmocytoma of the bone, and monoclonal immunoglobulindeposition diseases. SEP is usually found in the upper respi-ratory tract and secondary in the gastrointestinal tract, withonly 6.2 % arising in the large bowel [1]. Only fifteen case ofano-rectal SEP were reported in the English literature.The diagnosis of SEP requires demonstration of a mono-clonal plasma cell infiltration in organs other than the bonemarrow without evidence of systemic involvement [2].SEP patients mainly manifest with local masses and rele-vant symptoms, which are nonspecific and depend on the siteandspreadofthetumor.InthelowGItract,obstruction,rectalbleeding, and abdominal pain were more commonlydescribed.Amongplasmacellneoplasia,SEPshowsthebestprogno-sis with 10-year overall survival rate of 70 %. Although atransformation into MM has been described in a small per-centage of case (∼15%), patients with SEP that progressedtoMM had a 100 % 5-year survival rate [3].We reported a case of rectal SEP in a 60-years-old manpresented with a 1 month of history of painless hematocheziaand diarrhea. Past medical and surgical history of ischemicheart disease and femur fracture was reported.At physical examination, no palpable abdominal or rectalmass were detected.Colonoscopy revealed one small polyp in the cecum andthree polyps in the rectum, two small and one of large size.Endoscopic mucosal resection (EMR) was performed for thelargest.At macroscopic examination, the large rectal polyp, of 4×3×2.5 cm of size, showed a smooth surface superficiallyulcerated.Thesurgical margin wasinkedinblack.Atsection,thespecimenshowedafleshyandmulticysticappearanceandwas involved in toto. All sections were processed for histo-logical analysis.Thethreesmallsizepolypsweretubuloadenomawithlowgrade dysplasia.Histological analysis of the largest polyp showed massiveinfiltration by medium-sized cells, characterized by abundantpale to eosinophilic cytoplasm and eccentric nuclei with acartwheel arrangement of the chromatin. Neither mitosis norapoptotic figures were found. No residual rectal glands werefound. Congo red staining showed no amyloid deposits.At immunohistochemistry, tumor cells revealed diffusereactivity for CD138 and for immunoglobulin kappa lightchains. Immunostaining for lambda light chains, CD20,CD45 were negative on tumoral cells. Ki67 showed a lowproliferation rate. Immunostaining for CD3 revealed someaccompanying Tcells CD3+.A diagnosis of rectal plasmocytoma was retained.As rectal plasmocytomas are extremely rare, reactiveplasmacytosis, plasma cell granuloma, and lymphoma withplasma cell differentiation (mucosa-associated lymphoid tis-sue (MALT), lymphoblastic, and immunoblastic) have to beexcluded in order to avoid misdiagnosis.

Expanding the horizons of endoscopic ultrasound: diagnosis of non-digestive pathologies

Endoscopic ultrasound (EUS) is mainly used for the evaluation and sampling of mediastinal and abdominal lymph nodes, luminal and submucosal lesions of the upper and lower gastrointestinal tract, as well as in the diagnostic approach for pancreatic, biliary and liver disease. However, several non-digestive pathologies may be encountered as well, expanding the diagnostic potential of EUS. In this article, we present nine examples of extra-digestive abnormalities detected by means of EUS, including pathologies of the thyroid gland, mediastinal and abdominal vessels, lungs, kidney and the urinary bladder. The purpose of this article is to review the capabilities of EUS beyond routine evaluation of gastrointestinal organs.

Single operator endoscopic ultrasound-assisted rendezvous for the treatment of pancreaticocutaneous fistula.

Fig. 2. Fluoroscopic view of the deployed pancreatic stent. Endoscopic ultrasound (EUS)-guided rendezvous technique for pancreatic duct (PD) access has been described in several case series, with a success rate between 25 and 90% [1–6], including 4 patients with post-Whipple fistula [3,4,6]. However, the rendezvous was technically feasible in only two cases [3]. Hereby we present a case of successful management of a pancreaticocutaneous fistula with the rendezvous technique. A 50-year-old woman was referred for management of a pancreatic fistula, secondary to a surgical biopsy of an adenocarcinoma of the head of the pancreas A pancreatic stent placement was scheduled. However, selective access of the PD through the major papilla was technically difficult due to a previously deployed biliary uncovered self-expandable metal stent. In addition, access through the minor papilla, as well as through the fistula failed. For this reason an EUS-assisted rendezvous technique was attempted. The PD was punctured through the stomach with a linear array echoendoscope (Olympus, Belgium) and a 19-gauge needle (Boston Scientific, Belgium). Contrast medium injection confirmed correct positioning in the PD. Then a 0.025-inch guidewire (VisiGlide, Olympus) was advanced through the needle. After several unsuccessful attempts to advance the guidewire through the malignant stricture, it finally reached the duodenum through the minor papilla (Fig. 1). The echoendoscope was removed over the guidewire, and a duodenoscopewas inserted. The distal end of the guidewire exiting through the minor papilla was grasped with a snare and was withdrawnwith the endoscope from the mouth as a single