Jason N. Rogart

Targeted cyst wall puncture and aspiration during EUS-FNA increases the diagnostic yield of premalignant and malignant pancreatic cysts

BACKGROUND Characterization of pancreatic cysts by using EUS-FNA includes chemical and cytologic analysis. OBJECTIVE To evaluate whether material obtained from FNA of the cyst wall increases diagnostic yield. DESIGN Prospective series. SETTING Tertiary referral center. PATIENTS Consecutive patients with pancreatic cysts referred for EUS-FNA between March 2010 and March 2011. INTERVENTION FNA was performed with aspiration of cyst fluid for carcinoembryonic antigen (CEA) and cytology, followed by cyst wall puncture (CWP). CWP is defined as puncturing the far wall of the cyst and moving the needle back and forth through the wall to sample the wall epithelium. MAIN OUTCOME MEASUREMENTS The diagnostic yield for mucinous cystic pancreatic neoplasms by CEA and cytology obtained from cyst fluid compared with cytology obtained from CWP. CEA ≥192 ng/mL was considered mucinous. RESULTS A total of 69 pancreatic cysts from 66 patients were included. Adequate amounts of fluid were aspirated for CEA, amylase, and cytology in 60 cysts (81%). Cellular material adequate for cytologic assessment from CWP was obtained in 56 cysts (81%). Ten (30%) of 33 cysts with CEA <192 ng/mL and negative results of cyst fluid cytology had a mucinous diagnosis from CWP; 6 of 9 (67%) cysts with an insufficient amount of fluid for CEA analysis and cyst fluid cytology had a mucinous diagnosis from CWP. Furthermore, 4 malignant cysts were independently diagnosed by CWP cytology. The incremental diagnostic yield of CWP for mucinous or malignant cysts was therefore 29% (20 of 69 cysts, P = .0001). An episode of pancreatitis (1.45%) occurred. LIMITATION Lack of surgical criterion standard. CONCLUSIONS CWP during EUS-FNA is a safe and effective technique for improving the diagnostic yield for premalignant and malignant pancreatic cysts.

Fellow involvement may increase adenoma detection rates during colonoscopy.

BACKGROUND:Adenoma detection rate (ADR) is increasingly used as a quality indicator for screening/surveillance colonoscopy. Recent investigations to identify factors that affect ADR have focused on the technical aspects of the procedure or the equipment.OBJECTIVE:To assess whether gastroenterology (GI) fellow participation during colonoscopy affects ADR.METHODS:This is a retrospective study of data prospectively collected on 309 patients enrolled in a different study not involving polyp detection. In total, 126 colonoscopies were performed by a GI attending alone, and 183 by a GI fellow supervised by one of the same four GI attendings.RESULTS:The ADR was significantly higher when a fellow was involved (37% vs 23%, P < 0.01), as was the total number of adenomas detected (0.56 per patient vs 0.30 per patient, P < 0.05). The percentage of patients with two and three or more adenomas was also higher for fellows versus attendings alone (13.1% vs 5.6%, and 6% vs 1.6%, respectively; P < 0.05), though there was no difference in the detection of advanced adenomas (7.1% vs 5.6%, P = 0.16). The adenomas detected when fellows participated were smaller (mean size 4.4 mm vs 5.8 mm, P < 0.05), and more likely to be sessile (80.6% vs 64.9%, P < 0.05). There were no significant differences in the age, gender, indication for colonoscopy, or procedure time for the two groups.CONCLUSIONS:In this retrospective study, fellow involvement in colonoscopy may increase not only the ADR, but also the detection of more subtle adenomas. Further investigation into whether this is a “fellow effect,” or simply a matter of more efficient visual scanning and recognition with two people, should be considered.

Cyst wall puncture and aspiration during EUS-guided fine needle aspiration may increase the diagnostic yield of mucinous cysts of the pancreas.

Background Pancreatic cysts are common, however, their diagnosis and classification remains a challenge despite advances in cross-sectional imaging and endoscopic ultrasound with fine needle aspiration (EUS-FNA). Objective To determine the incremental yield of cytologic examination of material obtained from targeted fine needle aspiration (“puncture”) of the cyst wall after aspiration of fluid for CEA. Design Retrospective consecutive series. Patients and Setting Consecutive patients undergoing EUS-FNA of a pancreatic cyst by 2 expert endoscopists at a single tertiary care center between January 2006 and June 2008. Intervention Standard EUS-FNA of pancreatic cysts was carried out, and after cyst fluid aspiration the cyst wall was punctured and aspirated (CWP) to obtain epithelium for cytologic analysis. Main Outcome Measurements The diagnostic yields of carcinoembryonic antigen (CEA) obtained from cyst fluid and of cytology obtained from CWP. CEA greater than192 ng/mL was considered diagnostic of a mucinous cyst. Results One hundred seven patients underwent EUS-FNA with CWP. Sixteen (31%) of 52 patients with CEA <192 ng/mL had cytology positive for mucinous epithelium, whereas 15 (47%) of 32 cysts with an insufficient amount of fluid for CEA analysis had positive cytology from CWP. The additional, cumulative diagnostic yield for mucinous cysts was therefore, 37%. Of 55 cysts diagnosed as mucinous, more (56%) were diagnosed by CWP cytology alone than by CEA (P<0.05). Limitations Retrospective design and limited surgical pathology. Conclusions Cyst wall puncture and aspiration during routine EUS-FNA may be a safe, easily applied, and inexpensive technique for improving the diagnostic yield for mucinous cysts of the pancreas.

Analysis of endoscopic management of occluded metal biliary stents at a single tertiary care center

BACKGROUND A significant number of self-expandable metal stents (SEMSs) placed to palliate malignant biliary obstruction will occlude. Few data exist as to what constitutes optimal management. OBJECTIVE Our purpose was to review the management and outcomes of patients with biliary SEMS occlusion. DESIGN AND SETTING Retrospective chart review at a single tertiary care hospital. PATIENTS From January 1999 to October 2005, a total of 90 patients had SEMSs placed for malignant biliary obstruction, and 27 of these occluded. MAIN OUTCOME MEASUREMENTS Technical success of treating SEMS occlusion, stent patency and need for reintervention, and incremental cost analysis. RESULTS A total of 60 ERCPs were performed to treat SEMS occlusions in 27 patients. The success rate was 95%; however, 52% of patients eventually required more than 1 intervention. Placing a second SEMS through the existing SEMS (n = 14) provided the lowest reocclusion rate (43% vs 55% and 100%), the longest time to reintervention (172 days vs 66 and 43 days, P = .03), and a trend toward longer survival (285 days vs 188 and 194 days) compared with plastic stent and mechanical balloon cleaning, respectively. Incremental cost analysis showed both uncovered SEMSs and plastic stents to be cost effective strategies. LIMITATIONS Small number of patients, retrospective study. CONCLUSIONS Treatment of biliary SEMS occlusion with SEMS insertion provides for longer patency and survival, decreases the number of subsequent ERCPs by 50% compared with plastic stents, and is cost-effective.

Nurse Observation During Colonoscopy Increases Polyp Detection: A Randomized Prospective Study

OBJECTIVES:To determine whether a second observer during colonoscopy increases adenoma detection.METHODS:Consecutive patients undergoing screening colonoscopy were prospectively randomized to routine colonoscopy or physician and nurse observation during withdrawal.RESULTS:Of 502 patients, 249 were randomized to routine colonoscopy, and 253 to physician plus nurse observation during withdrawal. A total of 592 polyps were detected, 40 identified by the endoscopy nurse only. With nurse observation, 1.32 polyps and 0.82 adenomas were found per colonoscopy, vs. 1.03 polyps and 0.64 adenomas in the routine group, demonstrating a 1.29-fold and a 1.28-fold increase in the average number of polyps and of adenomas detected, respectively. The overall adenoma detection rate (ADR) was 44.1%, with trends toward increased ADR and all-polyp detection rate with nurse observation.CONCLUSIONS:Nurse observation during colonoscopy resulted in an increase in the number of polyps and adenomas found per colonoscopy, along with a trend toward improved overall ADR and all-polyp detection rate.

A Large Multicenter Experience With Endoscopic Suturing for Management of Gastrointestinal Defects and Stent Anchorage in 122 Patients: A Retrospective Review.

Goals:To describe a multicenter experience using an endoscopic suturing device for management of gastrointestinal (GI) defects and stent anchorage. Background:Endoscopic closure of GI defects including perforations, fistulas, and anastomotic leaks as well as stent anchorage has improved with technological advances. An endoscopic suturing device (OverStitch; Apollo Endosurgery Inc.) has been used. Study:Retrospective study of consecutive patients who underwent endoscopic suturing for management of GI defects and/or stent anchorage were enrolled between March 2012 and January 2014 at multiple academic medical centers. Data regarding demographic information and outcomes including long-term success were collected. Results:One hundred and twenty-two patients (mean age, 52.6 y; 64.2% females) underwent endoscopic suturing at 8 centers for stent anchorage (n=47; 38.5%), fistulas (n=40; 32.7%), leaks (n=15; 12.3%), and perforations (n=20; 16.4%). A total of 44.2% underwent prior therapy and 97.5% achieved technical success. Immediate clinical success was achieved in 79.5%. Long-term clinical success was noted in 78.8% with mean follow-up of 68 days. Clinical success was 91.4% in stent anchorage, 93% in perforations, 80% in fistulas, but only 27% in anastomotic leak closure. Conclusions:Endoscopic suturing for management of GI defects and stent anchoring is safe and efficacious. Stent migration after stent anchoring was reduced compared with published data. Long-term success without further intervention was achieved in the majority of patients. The role of endoscopic suturing for repair of anastomotic leaks remains unclear given limited success in this retrospective study.

Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study

BACKGROUND AND STUDY AIMS Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome. PATIENTS AND METHODS This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared. RESULTS A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups. CONCLUSIONS Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration.

Bile Duct Stones

In patients with choledocholithiasis gallstones can be located in the extraas well as in the intrahepatic bile ducts. Bile duct stones can be cholesterol concrements, and black and brown pigment stones. Cholesterol and black pigment stones exclusively originate from the gallbladder and therefore are called secondary bile duct stones. The brown calcium-bilirubinate stone is a primary bile duct stone, which originates from the bile ducts. In East Asia, brown bilirubinate stones can also be found in the gallbladder, but in Europeans it is extremely rare. The relative frequency of bile duct stones is 23% and increases with age as it does for gallbladder stones. In 30 years old persons it amounts to 5%, in 60 years old persons to 15% and in the 80th year of life to 50%. In 70–80%, bile duct stones are secondary concrements. Since these stones originate from the gallbladder they all have the characteristic cubic, pyramid-like or polygonal shape and can easily be identifi ed as secondary bile duct stones. Fifteen percent of all patients with cholecystolithiasis simultaneously have bile duct stones and 80–95% of patients with bile duct stones have gallbladder stones. Primary bile duct stones are round, cylindrical and layered due to their appositional growth and adapt their shape to the shape of the bile duct. Primary bile duct stones mostly develop after endoscopic or surgical manipulations of the biliary tree, and since bile duct stones proximal to stenoses, strictures or tumorous alterations as well as chronic infl ammation are diffi cult to treat, primary gallstones tend to recur. Also, after endoscopic sphincterotomy bile duct stones can develop if the sphincterotomy was not large enough, when extraand intrahepatic bile ducts are dilated, and the patient is of older age. Chapter Outline

The plastic biliary stent: an obsolete device for managing pancreatic cancer?

In 2009 there were an estimated 42,000 new cases of pancreatic cancer diagnosed. Patients with carcinoma of the head of the pancreas are subject to substantial morbidity resulting from obstruction of the intrapancreatic segment of the common bile duct. In patients who are not undergoing surgery, endoscopic treatment of malignant biliary obstruction is often successful in alleviating symptoms, reducing the incidence of cholangitis, and increasing biliary drainage so that hepatically metabolized chemotherapeutic agents can be offered. There is increasing general agreement, supported by a recent multicenter randomized control trial, that placing bile duct stents before pancreaticoduodenectomy increases the rates of serious complications. There is a paucity of data, however, regarding the patient population receiving neoadjuvant chemoradiotherapy in whom biliary drainage is required so that chemotherapeutic agents may be administered safely. This study by Boulay et al seeks to address this population, specifically examining the efficacy of plastic bile duct stents. Boulay et al deserve credit for studying this patient population; although the overall percentage of patients with ‘‘resectable’’ pancreatic cancer receiving neoadjuvant therapy in the United States is small (4.5% between 2000 and 2002), there are several studies over the last few years suggesting a possible benefit. Boulay et al evaluated, retrospectively, 49 patients with locally advanced pancreatic adenocarcinoma and biliary obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) and received plastic bile duct stents as a ‘‘bridge’’ to surgery before receiving neoadjuvant chemoradiotherapy. All procedures were carried out at a single institution, and all plastic stents were 10 French in diameter. Patients underwent 1 of 3 chemoradiation regimens, all of which were gemcitabine based. Only 29 (59%) patients subsequently underwent pancreaticoduodenectomy. Those who did not either had persistence/progression of disease or were unable to tolerate chemoradiation. Overall, 55% of the patients in the study underwent unplanned ERCP with stent exchange because of stent occlusion, which was manifested by rising liver tests, jaundice, or cholangitis. Two-thirds of these patients required hospitalization, often delaying or interrupting neoadjuvant therapy and one-third of patients required more than one ERCP for repeat occlusion. There was no statistical difference between rates of stent occlusion in patients who subsequently had surgical resection and those who did not. The overall median duration of stent patency was 134.5 days, which is consistent with other published reports, and 82.5 days in patients who occluded. This study provides practical information with regards to outcomes of plastic biliary stenting in patients receiving neoadjuvant chemoradiation, a group that has earlier been poorly studied. The results and conclusions presented by Boulay et al, however, should not be surprising to readers. Numerous studies have showed that the patency of plastic stents is on average only 2 to 4 months, and that self-expandable metal stents (SEMS) have longer patencies, result in fewer repeat procedures, and are more cost effective when used not only as the initial stent but also when used for treating occluded SEMS. In one of the earlier studies comparing plastic stents to SEMS, Davids et al showed a median patency of 126 days for plastic, compared with 273 days for metal stents. Additionally, their data exhibited that initial placement of SEMS in 100 patients would prevent 50 ERCPs and was cost-effective if the total costs related to one ERCP were less than

Foregut and Colonic Perforations: Practical Measures to Prevent and Assess Them

1760. In a Monte-Carlo decision analysis model, Chen et al, showed that a strategy of initially placing SEMS in patients whose surgical status is uncertain (comparable to the patient population studied by Boulay et al) resulted in a cost savings of nearly