Joan B. Gornals

A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study

BACKGROUND AND STUDY AIMSnA novel large-diameter, lumen-apposing, self-expanding metal stent with bilateral flanges was recently developed for endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic pancreatic fluid collections (PFCs). The aim of this study was to evaluate the efficacy and safety of this stent in a large cohort.nnnPATIENTS AND METHODSnPatients with a PFC undergoing EUS-guided drainage with this novel stent were prospectively enrolled in this multicenter cohort study.nnnRESULTSnThere were 61 patients: 46 patients (75u200a%) with walled-off necrosis (WON) and 15 (25u200a%) with a pancreatic pseudocyst. Stent placement was technically successful in 60 patients (98u200a%, 95u200a%CI 95u200a%u200a-u200a100u200a%). Clinical success, defined as resolution of clinical symptoms in combination with a decrease in the PFC size to ≤u200a2u200acm on imaging, was achieved in 93u200a% of patients with a pancreatic pseudocyst (95u200a%CI 77u200a%u200a-u200a100u200a%) and in 81u200a% of patients with WON (95u200a%CI 69u200a%u200a-u200a94u200a%). Treatment failure occurred in nine patients (16u200a%, 95u200a%CI 6u200a%u200a-u200a26u200a%), including four patients who required surgical intervention. Stent removal was performed in 82u200a% of patients after a median of 32 days (range 2u200a-u200a178) and was rated as easy in all but one patient. In 10 patients, endoscopic stent removal was not performed because of stent migration (nu200a=u200a3), stent dislodgement during necrosectomy (nu200a=u200a3), stent removal during surgery (nu200a=u200a2), or refusal by the patient (nu200a=u200a2). In total, five major complications were reported (9u200a%, 95u200a%CI 2u200a%u200a-u200a16u200a%), including PFC infection (nu200a=u200a4) and perforation (nu200a=u200a1).nnnCONCLUSIONnEUS-guided drainage using this novel stent is feasible and the clinical results obtained are promising with a low major complication rate.

Liver transplantation in patients with hepatic hydrothorax

Hepatic hydrothorax is a uncommon complication of cirrhotic patients and the results of liver transplantation (OLT) in patients with this complication are not well defined. We studied postoperative complications and survival of 28 patients with hepatic hydrothorax transplanted at our center during a period of 12u2003years, comparing them with a control group of 56 patients transplanted immediately before and after each case. There were no differences between hydrothorax group and control group in days of mechanical ventilation after surgery, transfusion requirements, postoperative mortality and long‐term survival (70% vs. 55% at 8u2003years, Pu2003=u20030.11). Long‐term evolution was similar between patients with refractory hepatic hydrothorax or spontaneous bacterial empyema and those with noncomplicated hepatic hydrothorax. Hepatic transplantation is an excellent therapeutic option for patients with hepatic hydrothorax. Presence of hepatic hydrothorax does not imply more postoperative complications, and long‐term survival is similar to other indications of hepatic cirrhosis.

Usefulness of endoscopic ultrasonography (EUS) for selecting carcinoid tumors as candidates to endoscopic resection

Introduction: carcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery. Objective: endpoints in this study included: —Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. —Assessing the effectiveness of local resection (complete car-cinoid resection) and the safety (complications) of the technique involved. Patients and methods: our series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), exci-sion was carried out with conventional polypectomy snare muco-sectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following non-curative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resec-tion: CR) and safety (complications). Results: there were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%). EUS sensitivity was 94%. Complete resection was 90.5% (19/21).INTRODUCTIONnCarcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery.nnnOBJECTIVEnEndpoints in this study included:--Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. --Assessing the effectiveness of local resection (complete carcinoid resection) and the safety (complications) of the technique involved.nnnPATIENTS AND METHODSnOUr series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty-one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), excision was carried out with conventional polypectomy snare mucosectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following non-curative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resection: CR) and safety (complications).nnnRESULTSnThere were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%).EUS sensitivity was 94%. Complete resection was 90.5% (19/21).nnnCONCLUSIONSnThe endoscopic mucosal resection of selected carcinoid tumors is a safe, effective technique. EUS is the technique of choice to select patients eligible for endoscopic resection (carcinoids smaller than 20 mm in superficial layers, with an unscathed muscularis propria and negative extension study).

Successful treatment with tenofovir in a child C cirrhotic patient with lamivudine-resistant hepatitis B virus awaiting liver transplantation. Post-transplant results.

Antiviral treatment can be complex in decompensated hepatitis B virus (HBV) cirrhosis because of potential emergence of lamivudine‐resistant mutants and worsening liver function, and to multifactorial nephrotoxicity. Negative HBV‐DNA status by hybridization before liver transplantation is a favorable prognostic factor. We present the case of a 54‐year‐old HBV+ liver transplantation candidate who, after testing negative for HBV‐DNA, developed YMDD lamivudine‐resistant mutants resulting in a deteriorated clinical condition. After 8u2003months of adefovir plus lamivudine double therapy, only partial response was achieved. Tenofovir was added to this regimen, and an early decline of HBV‐DNA was seen at 4u2003weeks without adverse events. The patient underwent transplantation. At 21‐month postoperative follow‐up, the patients outcome was excellent. Post‐transplantation HBV prophylaxis, taking into account the prior development of mutants, consists of hepatitis B immunoglobulin plus lamivudine and adefovir. Tenofovir was well tolerated and produced a fast antiviral response, suggesting its potential value in combined antiviral treatment for liver transplantation candidates.

Definitive diagnosis of neuroendocrine tumors using fine-needle aspiration-puncture guided by endoscopic ultrasonography.

BACKGROUNDnThe detection and diagnosis of neuroendocrine tumors (NETs) is challenging. Endoscopic ultrasonography (EUS) has a significant role in the detection of NETs suspected from clinical manifestations or imaging techniques, as well as in their precise localization and cytological confirmation using EUS-Fine-needle aspiration-puncture (FNA).nnnOBJECTIVEnTo assess the usefulness and precision of EUS-FNAP in the differential diagnosis and confirmation of NETs, in a retrospective review of our experience.nnnPATIENTS AND METHODSnin a total of 55 patients with suspected NETs who underwent radial or sectorial EUS, 42 tumors were detected in 40 cases. EUS-FNA using a 22G needle was performed for 16 cases with suspected functional (hormonal disorders: 6 cases) and non-functional NETs (10 cases). Ki 67 or immunocytochemistry (ICC) testing was performed for all.There was confirmation in 9 cases (5 female and 4 male) with a mean age of 51 years (range: 41-81 years).All tumors were located in the pancreas except for one in the mediastinum and one in the rectum, with a mean size of 19 mm (range: 10-40 mm).nnnRESULTSnThere were no complications attributable to FNA. Sensitivity was 100% and both precision and PPV were 89%, as a false positive result suggested a diagnosis with NET during cytology that surgery finally revealed to be a pancreatic pseudopapillary solid tumor.nnnCONCLUSIONSnEUS-FNA with a 22G needle for NETs has high sensitivity and PPV at cytological confirmation with few complications.

Endoscopic ultrasound-guided transesophageal drainage of a mediastinal pancreatic pseudocyst using a novel lumen-apposing metal stent.

There have been a few previous reports of transesophageal endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFC). In these reports the drainage modality has been a single aspiration or deployment of a plastic stent [1–4]. We report a patient who underwent transesophageal EUS-guided drainage of a mediastinal PFC using a novel lumen-apposing metal stent. A 37-year-old man with a history of rightsided pneumothorax and four episodes of acute pancreatitis was referred for drainage of a PFC. He was experiencing abdominal pain and cysts of increasing size had been seen on his imaging procedures. Computed tomography (CT) scanning revealed an 80×50-mm PFC, which had herniated into the mediastinum adjacent to the lower esophagus. The PFC was accessed from the lower esophagus using a linear echoendoscope and a novel access device (NAVIX; Xlumena Inc., Mountain View, California, USA) that enables dilation of a tract up to 10mm and placement of a guide wire. Once the cystoesophagostomy had been created, a fully covered metal stent with bilateral anchor flanges that can appose nonadherent lumens (AXIOS, 10×10mm; Xlumena) was placed across the tract (● Fig.1,● Fig.2 and● Video 1) and 900 mL of fluid was aspirated. An immediate chest radiograph revealed a tension pneuFig.1 View during endoscopic ultrasound (EUS)-guided placement of a lumen-apposing metal AXIOS stent across the cystoesophagostomy.

Single-session endosonography and endoscopic retrograde cholangiopancreatography for biliopancreatic diseases is feasible, effective and cost beneficial.

BACKGROUNDnEndoscopic ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are often required in patients with pancreaticobiliary disorders.nnnAIMSnTo assess the clinical impact and costs savings of a single session EUS-ERCP.nnnMETHODSnPatient and intervention data from April 2009 to March 2012 were prospectively recruited and retrospectively analyzed from a database at a tertiary hospital. Indications, diagnostic yield, procedure details, complications and costs were evaluated.nnnRESULTSnFifty-five scheduled combined procedures were done in 53 patients. The accuracy of EUS-fine needle aspiration for malignancy was 90%. The main clinical indication was a malignant obstructing lesion (66%). The ERCP cannulation was successful in 67%, and in 11/15 failed ERCP (73%), drainage was completed thanks to an EUS-guided biliary drainage: 6 transmurals, 5 rendezvous. Eight patients (14%) had related complications: bacteremia (n = 3), pancreatitis (n = 2), bleeding (n = 2) and perforation (n = 1). The mean duration was 65 ± 22.2 min. The mean estimated cost for a single session was €3437, and €4095 for two separate sessions. The estimated cost savings using a single-session strategy was €658 per patient, representing a total savings of €36,189.nnnCONCLUSIONnCombined EUS and ERCP is safe, technically feasible and cost beneficial. Furthermore, in failed ERCP cases, the endoscopic biliary drainage can be completed with EUS-guided biliary access in the same procedure.

Pancreatic endocrine tumors or apudomas.

INTRODUCTION AND OBJECTIVEnpancreatic endocrine tumors (PET) are difficult to diagnose. Their accurate localization using imaging techniques is intended to provide a definite cure. The goal of this retrospective study was to review a PET series from a private institution.nnnPATIENTS AND METHODSnthe medical records of 19 patients with PETs were reviewed, including 4 cases of MEN-1, for a period of 17 years (1994-2010). A database was set up with ten parameters: age, sex, symptoms, imaging techniques, size and location in the pancreas, metastasis, surgery, complications, adjuvant therapies, definite diagnosis, and survival or death.nnnRESULTSna total of 19 cases were analyzed. Mean age at presentation was 51 years (range: 26-67 y) (14 males, 5 females), and tumor size was 5 to 80 mm (X: 20 mm). Metastatic disease was present in 37% (7/19). Most underwent the following imaging techniques: ultrasounds, computed tomography (CT) an magnetic resonance imaging (MRI). Fine needle aspiration punction (FNA) was performed for the primary tumor in 4 cases. Non-functioning: 7 cases (37%), insulinoma: 2 cases [1 with possible multiple endocrine neoplasia (MEN)], Zollinger-Ellison syndrome (ZES) from gastrinoma: 5 (3 with MEN-1), glucagonoma: 2 cases, 2 somatostatinomas; carcinoid: 1 case with carcinoide-like syndrome. Most patients were operated upon: 14/19 (73%). Four (4/14:28%) has postoperative complications following pancreatectomy: pancreatitis, pseudocyst, and abdominal collections. Some patients received chemotherapy (4), somatostatin (3) and interferon (2) before or after surgery. Median follow-up was 48 months. Actuarial survival during the study was 73.6% (14/19).nnnCONCLUSIONSnage was similar to that described in the literature. Males were predominant. Most cases were non-functioning (37%). Most patients underwent surgery (73%) with little morbidity (28%) and an actuarial survival of 73.6% at the time of the study.

Endoscopic closure of duodenal perforation with an over-the-scope clip during endoscopic ultrasound-guided cholangiopancreatography

A 74-year-old woman presented obstructive jaundice. Computed tomography revealed a pancreatic head tumor with dilatation of the common bile duct (CBD) and pulmonary metastases. Biliary drainage by ERCP was indicated. Papilla had tumoral signs of infiltration. Cannulation was not achieved after several attempts with a papillotome. We accessed the distal CBD after performing a pre-cut, but the guidewire could not pass deeply. After replacing the duodenoscope with a linear echoendoscope with the intention of performing biliary drainage guided by EUS, a 10 mm duodenal perforation (type I, Stapfer) was visualized in the posterior wall of the duodenal bulb (Fig. 1A), surely caused by the tip of the echoenEndoscopic closure of duodenal perforation with an over-the-scope clip during endoscopic ultrasound-guided cholangiopancreatography

Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen

Treatment of locally advanced esophageal cancers with high-dose definitive concomitant chemoradiotherapy can lead to high-grade esophageal strictures, or, rarely, total obliteration of the lumen. Strictures can be successfully treated with various endoscopic techniques; however, complete obstruction is a technically challenging problem. Anterograde endoscopic techniques carry the risk of perforation or bleeding. A combined anterograde–retrograde dilation technique, described in a few reports, is another option but requires retrograde access through a prior ostomy [1–4]. We report a novel method for managing complete esophageal obstruction using endoscopic ultrasound (EUS)-guided puncture for access to the distal lumen, previously described only in a case of total colonic stricture using a prototype forward-view echoendoscope [5]. A 62-year-old woman had received highdose chemoradiation for a squamous cell esophageal carcinoma (stage IIIC) and her esophagus had completely occluded, with severe compromise to her quality of life (● Fig.1). Several attempts to pass a guide wire though the stricture were unsuccessful. We decided to attempt recanalization of the lumen using an EUS-guided access. The linear echoendoscope (GF-UCT140AL5;Olympus, Tokyo, Japan)wasadvanced 24cm from the incisors and the distal esophageal lumenwas identified from the proximal endon theEUSimage (● Fig.2a). A 19G needle (Expect Flex; Boston Scientific Corp, Natick, Massachusetts, USA) was used to puncture the obstructed lumen under EUS guidance (● Fig.2b). Contrast filling was visualized under fluoroscopy and a 0.035-inch guide wire (Microvasive Jagwire; Boston Scientific) was advanced through the EUS needle (● Fig.3a,b). An 8-mm biliary balloon (Hurricane RX; Boston Scientific) was used to perform a first dilation under endoscopic and fluoroscopic guidance (● Fig.3c). The endoscopic appearance after dilation was satisfactory, with reestablishment of luminal continuity (● Video 1). The patient underwent four additional endoscopic balloon dilations of up to 15mm (● Fig.4). She respondedwell, gaining the ability to swallow secretions, drinks, and soft food, andwithout evidence of delayed complications. Fig.2 a,b EUS images of the esophageal total stricture. a A thickened esophageal wall (arrows) continues through the stenosis. b EUS image of the 19G needle through the stricture (arrow).