Jessica Trevino

Randomized trial comparing the 22-gauge aspiration and 22-gauge biopsy needles for EUS-guided sampling of solid pancreatic mass lesions

BACKGROUND To overcome limitations of cytology, biopsy needles have been developed to procure histologic samples during EUS. OBJECTIVE To compare 22-gauge (G) FNA and 22G biopsy needles (FNB) for EUS-guided sampling of solid pancreatic masses. DESIGN Randomized trial. SETTING Tertiary-care medical center. PATIENTS This study involved 56 patients with solid pancreatic masses. INTERVENTION Sampling of pancreatic masses by using 22G FNA or 22G FNB devices. MAIN OUTCOME MEASUREMENTS Compare the median number of passes required to establish the diagnosis, diagnostic sufficiency, technical performance, complication rates, procurement of the histologic core, and quality of the histologic specimen. RESULTS A total of 28 patients were randomized to the FNA group and 28 to the FNB group. There was no significant difference in median number of passes required to establish the diagnosis (1 [interquartile range 1-2.5] vs 1 [interquartile range 1-1]; P = .21), rates of diagnostic sufficiency (100% vs 89.3%; P = .24), technical failure (0 vs 3.6%; P = 1.0), or complications (3.6% for both) between FNA and FNB needles, respectively. Patients in whom diagnosis was established in passes 1, 2, and 3 were 64.3% versus 67.9%, 10.7% versus 17.9%, and 25% versus 3.6%, respectively, for FNA and FNB cohorts. There was no significant difference in procurement of the histologic core (100% vs 83.3%; P = .26) or the presence of diagnostic histologic specimens (66.7% vs 80%; P = .66) between FNA and FNB cohorts, respectively. LIMITATIONS Only pancreatic masses were evaluated. CONCLUSION Diagnostic sufficiency, technical performance, and safety profiles of FNA and FNB needles are comparable. There was no significant difference in yield or quality of the histologic core between the 2 needle types.

Randomized trial comparing fanning with standard technique for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic mass lesions

BACKGROUND AND STUDY AIMS The fanning technique for endoscopic ultrasound-guided fine-needle aspiration (EUS - FNA) involves sampling multiple areas within a lesion with each pass. The aim of this study was to compare the fanning and standard techniques for EUS - FNA of solid pancreatic masses. PATIENTS AND METHODS Consecutive patients with solid pancreatic mass lesions were randomized to undergo EUS - FNA using either the standard or the fanning technique. The main outcome measure was the median number of passes required to establish diagnosis. The secondary outcome measures were the diagnostic accuracy, technical failure, and complication rate of the two techniques. RESULTS Of 54 patients, 26 were randomized to the standard technique and 28 to the fanning technique. There was no difference in diagnostic accuracy (76.9 % vs. 96.4 %; P = 0.05), technical failure or complication rates (none in either cohort). There was a significant difference in both the number of passes required to establish diagnosis (median 1 [interquartile range 1 - 3] vs. 1 [1 - 1]; P = 0.02) and the percentage of patients in whom a diagnosis was achieved on pass one (57.7 % vs. 85.7 %; P = 0.02) between the standard and fanning groups, respectively. CONCLUSIONS The fanning technique of FNA was superior to the standard approach because fewer passes were required to establish the diagnosis. If these promising data are confirmed by other investigators, consideration should be given to incorporating the fanning technique into routine practice of EUS - FNA. Registered at Clinical Trials.gov (NCT 01501903).

Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections

Background and Aim:  The role of pancreatic duct (PD) stenting in patients undergoing endoscopic transmural drainage of peripancreatic fluid collection (PFC) remains unclear. The objective of this study is to evaluate the effect of PD stenting on treatment success in patients undergoing endoscopic transmural drainage of PFC.

Initial experience with the prototype forward-viewing echoendoscope for therapeutic interventions other than pancreatic pseudocyst drainage (with videos)

BACKGROUND The current oblique-viewing echoendoscope can occasionally be limited in its ability to perform therapeutic interventions because of the acute angle at which endoscopic accessories passed via the biopsy channel make contact with the gut wall. In an effort to overcome this limitation, a prototype forward-viewing echoendoscope was developed and successfully tested for performing transgastric drainage of pancreatic pseudocysts. OBJECTIVE Evaluation of an initial experience with the prototype forward-viewing echoendoscope for performing interventions such as bile-duct drainage, pelvic-abscess drainage, and fiducial marker placement via the transduodenal and transrectal approaches. DESIGN A retrospective study. SETTING An academic tertiary-referral center. PATIENTS Three patients. INTERVENTIONS By using the prototype forward-viewing echoendoscope, transduodenal drainage of an obstructed bile duct, transrectal drainage of a pelvic abscess, and placement of fiducial markers in a rectal cancer were undertaken in 3 patients. MAIN OUTCOME MEASUREMENTS To evaluate the feasibility of performing interventions via the transduodenal and transrectal approaches by using the prototype forward-viewing echoendoscope. OBSERVATIONS The procedures were technically successful in all 3 patients, and no procedural complications were encountered. The passage of accessories and the deployment of stents were technically easy with the forward-viewing echoendoscope. In addition, there was no need to reorient the position of the echoendoscope when switching from a sonographic to endoscopic view while performing therapeutic interventions. LIMITATION Small number of patients. CONCLUSIONS It was feasible to perform interventions such as drainage of an obstructive bile duct and a pelvic abscess, and placement of fiducial markers via the transduodenal and transrectal approaches by using the prototype forward-viewing echoendoscope. Further studies that include larger numbers of patients are needed to evaluate the role of the forward-viewing echoendoscope for performing EUS-guided therapeutic interventions.

The use of endoscopic ultrasound-guided gold markers in image-guided radiation therapy of pancreatic cancers: a case series

While endoscopic ultrasound (EUS)-guided fiducial placement is technically feasible, its role in the delivery of image-guided radiation therapy (IGRT) is unclear. In this study, we evaluated the feasibility and safety of using EUS-guided fiducial markers for delivering IGRT in patients with pancreatic cancer. Following computed tomography (CT) simulation, a radiation therapy treatment plan was prepared for each patient. A kilovoltage (kv) image obtained before each treatment session was aligned with images generated during treatment planning, based on the position of fiducials. Radiation therapy was then delivered. Image analysis was also performed by alignment of bony landmarks (current standard of care). Daily shifts of fiducials between the two sets of images represented movement of the pancreas relative to the bony landmarks. EUS-guided fiducial placement was technically successful in all nine patients and no complications were encountered. The fiducials were easily identified for image fusion and IGRT was delivered successfully to all patients. The movement of the pancreas relative to bones was 0.2 cm (0.1-0.5 cm), 0.5 cm (0.2-1.5 cm), and 0.4 cm (0.2-0.9 cm) in the anterior-posterior, superior-inferior, and left-right axes, respectively. This technique may have significant clinical implications in terms of radiation dosimetry.

Modified technique for EUS-guided drainage of pelvic abscess (with video).

BACKGROUND We previously described a technique for EUS-guided drainage of pelvic abscess by means of transrectal catheter placement. However, drainage catheters are prone to accidental dislodgement, and their management has mandated a prolonged inpatient hospital stay. OBJECTIVE To evaluate the effectiveness of a combined technique by using EUS-guided transrectal drainage catheter and stent placement for management of patients with pelvic abscesses. DESIGN An observational study. SETTING Academic tertiary-referral center. PATIENTS Four patients underwent EUS-guided drainage of pelvic abscesses that were not amenable for drainage by US and/or CT guidance. INTERVENTIONS A 10F drainage catheter and one or two 7F double-pigtail stents were deployed in the abscess cavity under EUS guidance. Subsequently, the drainage catheter was periodically flushed and aspirated for 36 hours until improvement in size of the abscess was confirmed by CT imaging. The drainage catheter was then discontinued, and the patients were discharged from the hospital. If resolution of the abscess was noted on outpatient CT at 2 weeks, then the stents were retrieved by sigmoidoscopy. MAIN OUTCOMES MEASUREMENTS Short-term treatment success was defined as improvement in clinical symptoms and a decrease in size of the pelvic abscess on postprocedure CT obtained at 36 hours. Medium-term treatment success was defined as resolution of clinical symptoms and pelvic abscess on follow-up CT at 2 weeks. RESULTS The procedure was technically successful in all 4 patients. The mean size of the abscess was 93 x 61 mm. No procedural complications were encountered. Treatment was successful both in the short and medium term in all 4 patients, and the mean duration of the postprocedure hospital stay was 2 days. At a mean follow-up of 221 days (range, 65-416 days), all 4 patients were doing well, without any symptoms of pelvic-abscess recurrence. LIMITATIONS The small number of patients and the absence of a comparative treatment group. CONCLUSIONS The combined placement of a transrectal drainage catheter and a stent under EUS guidance was a technically feasible, safe, and effective technique for management of patients with pelvic abscess. This technique minimized the possibility of accidental dislodgement of the drainage catheter and facilitated earlier patient discharge from the hospital.

Factors impacting treatment outcomes in the endoscopic management of walled-off pancreatic necrosis

Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled‐off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset.

Objective assessment of an algorithmic approach to EUS-guided FNA and interventions

BACKGROUND Despite an increasing number of procedures being performed, there is no consensus on an optimal approach to EUS-guided FNA (EUS-FNA) or interventions. OBJECTIVE Validate an algorithmic approach to EUS-FNA/interventions with the objective of improving technical outcomes and resource use. DESIGN Prospective study. SETTING Tertiary-care referral center. PATIENTS Consecutive patients undergoing EUS-FNA and/or interventions. INTERVENTION Phase I was a retrospective analysis of EUS-FNA/interventions performed in 548 patients. The 19-gauge needle was used for interventions, and the 22- or 25-gauge needle was used interchangeably for performing FNAs. At phase I, the technical failure rate was 11.5%. Based on these observations, an algorithm was proposed by which all transduodenal FNAs were performed by using a 25-gauge needle and other FNAs with a 22-gauge needle. All transduodenal interventions were performed with a Flexible 19-gauge needle and others with a standard 19-gauge needle. This algorithm was tested prospectively in phase II on 500 patients. MAIN OUTCOME MEASUREMENTS Compare technical failure, diagnostic adequacy, procedural complications, and average needle costs between both phases. RESULTS The technical failure rate was significantly less in phase II compared with that of phase I (1.6% vs 11.5%; P < .001) for both FNA (1.8% vs 10.9%; P < .001) and therapeutic interventions (0% vs 16.4%; P = .001). Although there was no difference in diagnostic adequacy (97.1% vs 98.4%; P = .191) or complications (0.4% vs 0.2%; P = 1.0) between phases I and II, the average cost per case was significantly less in phase II (

Comparison of outcomes between endoscopic ultrasound-guided transcolonic and transrectal drainage of abdominopelvic abscesses.

199.59 vs

EUS for the management of peripancreatic fluid collections after distal pancreatectomy

188.30; P = .008). LIMITATIONS Single-center study. CONCLUSION An algorithmic approach to EUS-FNA/interventions yielded better technical outcomes and cost savings without compromising diagnostic adequacy.