Ji Young Bang

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).

Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual

Lumen-apposing metal stents (LAMS) have been recently developed to improve treatment outcomes in the endoscopic management of pancreatic fluid collections (PFC), particularly in walled-off necrosis (WON), to facilitate better drainage of necrotic contents and minimise the risk of perforation and peritoneal leakage. In an ongoing randomised trial, we observed serious adverse events that included delayed bleeding, buried stent syndrome and biliary stricture that necessitated a change in the management protocol for patients with PFC treated with LAMS. Randomised trials comparing endoscopic and surgical techniques for the management of PFCs have favoured the endoscopic approach.1 ,2 Endoscopy is less expensive, associated with shorter hospital stay and the clinical outcomes are comparable. To compare the clinical outcomes of patients undergoing endoscopic drainage of WON using LAMS or plastic stents, a randomised trial (NCT02685865) was initiated at our institution. Included in the study were patients with symptomatic WON measuring >6 cm in size and located adjacent to the gastric or duodenal lumen. Excluded were patients with pseudocysts, WON inaccessible for endoscopic ultrasound-guided drainage and irreversible coagulopathy. The LAMS (Hot AXIOS, Boston Scientific) used in this trial had a single-step cautery-tipped delivery system with dimensions of 15 mm (diameter) by 10 mm (length). In the plastic stent cohort, two 7 Fr by 4 cm double pigtail stents were deployed after dilation of the transmural tract to 12 mm. Per study protocol, a follow-up CT was obtained at 4–6 weeks after the index intervention to assess treatment response with treatment success defined as resolution of WON to <3 cm in conjunction with symptom relief. The main outcome measure was to compare the median number of interventions required to achieve treatment success. The secondary outcome measures were to compare the rates of treatment success and clinical and stent-related adverse events. The total sample size was estimated at 62 patients. In this ongoing …

Assessment of the technical performance of the flexible 19-gauge EUS-FNA needle

BACKGROUND A needle made of nitinol has been developed with enhanced flexibility to overcome the limitations of the currently available 19-G EUS-FNA needles. OBJECTIVE Evaluate the ability to perform transduodenal FNAs, procure histologic specimens, and undertake therapeutic interventions using the flexible 19-G needle. DESIGN Prospective cohort study. SETTING Tertiary-care academic medical center. PATIENTS Consecutive patients with subepithelial masses, pancreatic head or uncinate lesions, or lesions adjacent to the pancreatic head, and patients undergoing therapeutic intervention. INTERVENTIONS Perform tissue acquisition and interventions with the flexible 19-G FNA needle. MAIN OUTCOME MEASURES Evaluate the ability to perform transduodenal passes with the flexible 19-G FNA needle. Also, assess the utility of the needle to yield both cytologic and histologic samples and to perform therapeutic interventions. RESULTS Of the 50 patients enrolled, tissue acquisition was undertaken in 38 and therapeutic intervention in 12. Of 38 patients from whom tissue was procured, 32 tissue samples were from pancreatic head/uncinate or peripancreatic masses and 6 were from subepithelial masses. Tissue acquisition, which included transduodenal passes, was successful and adequate for cytologic assessment in all 38 patients (100%). Satisfactory histologic specimens were procured from 36 of 38 (94.7%) patients. An onsite diagnosis was established in 35 of 38 (92.1%) patients. In 3 patients with indeterminate/suspicious lesions, a definitive diagnosis was established at histology. A mean of 1.45 ± 0.79 passes per patient was performed. All 12 therapeutic interventions were successful (100%) and included pseudocyst drainage in 5, pelvic abscess drainage in 2, fiducial placement in 2, celiac plexus neurolysis in 2, and cholangiogram in 1. Needle dysfunction or procedural complications were not encountered. LIMITATIONS Single-center study with limited power. CONCLUSIONS Preliminary data suggest that the flexible 19-G needle can be used for procuring cytologic aspirates and histologic specimens and to undertake therapeutic interventions even by the transduodenal route. Confirmatory studies are required in a larger cohort of patients with varied pathologic conditions to validate these findings.

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 (

Lumen‐apposing metal stents for drainage of pancreatic fluid collections: When and for whom?

199.59 vs

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

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.

Outcomes after implementing a tailored endoscopic step‐up approach to walled‐off necrosis in acute pancreatitis

Although lumen‐apposing metal stents (LAMS) are increasingly being used for drainage of pancreatic fluid collections (PFC), their advantage over plastic stents is unclear.

Endoscopic Ultrasound-Guided Management of Pancreatic Pseudocysts and Walled-Off Necrosis

Transrectal endoscopic ultrasound (EUS)‐guided pelvic abscess drainage has been reported, but data on transcolonic drainage are scant.