Kalpesh K. Patel

Single-step endoscopic ultrasonography-guided drainage of peripancreatic fluid collections with a single self-expandable metal stent and standard linear echoendoscope.

Endoscopic ultrasonography (EUS)-guided drainage of peripancreatic fluid collections (PFCs) is a well described alternative to surgery or percutaneous drainage. However, it is limited by the requirement for a large working channel that allows multiple plastic stent placement, which is only commercially available on therapeutic linear echoendoscopes. Herein, we describe the drainage of PFCs with a single self-expandable metal stent (SEMS) using a single-step technique and standard linear echoendoscope. Seven cases were identified during a retrospective chart review, and included all patients who had undergone EUS-guided drainage of PFCs during a 6-month period. The mean age was 46 years (range 25 - 70 years) and all patients were symptomatic. The mean diameter of PFCs was 8 cm (range 4.1 - 12.5 cm). Previous percutaneous drainage had failed in three patients. A total of 10 PFCs were drained. Three patients had two cysts drained by the same stent and one patient had two separate procedures to drain two distinct cysts. The SEMS was in place for a mean of 13 weeks (range 4 - 34 weeks). Successful placement of SEMS was achieved in all seven cases. Patients were followed for a mean of 18 weeks (range 7 - 35 weeks), and symptom improvement was achieved in all cases. Complete resolution of PFC was achieved in 9 /10 cysts. No complications were encountered. Single-step EUS-guided drainage of PFCs using a single 10-mm SEMS and a standard linear echoendoscope appears to be a feasible endoscopic technique with excellent technical and clinical success rates.

Comparison of endoscopic ultrasound guided 22-gauge core needle with standard 25-gauge fine-needle aspiration for diagnosing solid pancreatic lesions

Background and Objectives: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the standard modality for diagnosing pancreatic masses. We compared the diagnostic yield of a new EUS-guided 22-gauge core needle biopsy to a standard 25-gauge FNA in sampling the same pancreatic lesions during the same EUS. Patients and Methods: The main outcomes of the study were the sample adequacy of each method to provide a final pathological diagnosis, and the concordance in diagnosis between core and FNA specimens. The secondary outcomes were the sensitivity and specificity of the findings for each needle and the incremental yield of using both needles compared with using each needle alone. Results: A total of 56 patients with 61 solid pancreatic lesions were evaluated. The mean number of passes with FNA was 3.5 (ranges 1-8) and with core biopsy needle was 1.7 (ranges 1-5). The proportions of adequate samples were 50/61 (81.9%) for FNA and 45/61 (73.8%) for core biopsy (P = 0.37). The diagnostic yield was 46/61 (75.4%), 42/61 (68.9%) and 47/61 (77.1%) for FNA, core, and both, respectively. There was a substantial agreement of 87.5% (κ = 0.77; P < 0.001) in the findings of core and FNA specimens. The sensitivity for the diagnosis of malignancy for FNA and core biopsy were 68.1% and 59.6%, respectively (P = no significant [NS]). The specificity was 100% for both methods. The incremental increase in sensitivity and specificity by combining both methods are 1.5% and 0%, respectively. Conclusion: There are NS differences in the diagnostic yield between EUS-guided 22-gauge core biopsy and standard 25-gauge FNA for diagnosing pancreatic lesions, but core biopsy required fewer numbers of passes. There was NS incremental diagnostic yield when using both needles during the same procedure.

Endoscopic ultrasound-guided fine-needle aspiration with on-site cytopathology versus core biopsy: a comparison of both techniques performed at the same endoscopic session.

Background: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) with bedside cytopathology is the gold standard for assessment of pancreatic, subepithelial, and other lesions in close proximity to the gastrointestinal tract, but it is time-consuming, has certain diagnostic limitations, and bedside cytopathology is not widely available. Aims: The goal of this study is to compare the diagnostic yield of EUS-guided FNA with on-site cytopathology and EUS-guided core biopsy. Methods: Twenty-six patients with gastrointestinal mass lesions requiring biopsy at a tertiary medical center were included in this retrospective analysis of a prospective cohort. Two core biopsies were taken using a 22 gauge needle followed by FNA guided by a bedside cytopathologist at the same endoscopic session. The diagnostic yield and test characteristics of EUS core biopsy and EUS FNA with bedside cytopathology were examined. Results: The mean number of passes was 3.2 for FNA, and the mean procedure time was 39.4 minutes. The final diagnosis was malignant in 92.3 %. Sensitivity and specificity were 83 % and 100 %, respectively, for FNA, and 91.7 % and 100 %, respectively, for core biopsy. Diagnostic accuracy was 92.3 % for FNA and 84.6 % for core biopsy. The two approaches were in agreement in 88.4 % with a kappa statistic of 0.66 (95 % confidence interval 0.33 – 0.99). Conclusions: An approach using two passes with a core biopsy needle is comparable to the current gold standard of FNA with bedside cytopathology. The performance of two core biopsies is time-efficient and could represent a good alternative to FNA with bedside cytopathology.

Quality Improvement Primer Series: The Plan-Do-Study-Act Cycle and Data Display

*Division of Gastroenterology, Department of Medicine, Women’s College Hospital; Division of Gastroenterology, Division of Nephrology, Department of Medicine, St. Michael’s Hospital, kDivision of Gastroenterology, Department of Medicine, Sunnybrook Health Sciences Centre; Division of Gastroenterology, Department of Medicine, University Health Network; Division of Internal Medicine, Department of Medicine, Mount Sinai Hospital Centre for Inflammatory Bowel Disease; **Institute of Health Policy, Management and Evaluation University of Toronto, Ontario, Canada; Section of Gastroenterology and Hepatology, Baylor School of Medicine, Houston, Texas

Applying Lean Design Principles to a Gastrointestinal Endoscopy Program for Uninsured Patients Improves Health Care Utilization

There is an emerging national consensus to increase colon and rectal cancer (CRC) screening rates to 80% by 2018. For us, as a nation (and GI specialty) to move from our current 60% to 80% we have to enhance screening among patient populations that are challenged to access our medical system. Those who are underinsured or uninsured pose a special challenge. In this month’s Practice Management column, gastroenterologists in Houston, Texas describe the impact of lean management strategies to enhance colon and rectal cancer screening among lowincome patients in the Harris Health System. Readers are encouraged to refer to a previous article, which focused on similar patients in Connecticut (Lagarde SP. No one left behind: the road to 80% by 2018. Clin Gastroenterol Hepatol 2014;12:1212–1215).

Cholangioscopy is Safe and Feasible in Elderly Patients

BACKGROUND & AIMS Although cholangioscopy is widely used during endoscopic retrograde cholangiopancreatiography (ERCP), its safety and feasibility for elderly patients are not well established. We aimed to evaluate the safety and feasibility of cholangioscopy in elderly patients. METHODS We performed a retrospective study of all ERCPs with single‐operator cholangioscopy (SOC) performed at 3 tertiary referral hospitals from March 2012 through October 2015. We collected data on patient demographics, procedure indications, findings, complications, and success rates (complete success was achieved if all intended diagnostic and therapeutic procedures were performed, such as tissue sample collection or complete removal of stones). The cohort was divided into 3 groups: patients younger than 65 years (group 1, n = 178), patients 65–75 years old (group 2, n = 86), and patients older than 75 years (group 3, n = 77). We used 1‐way ANOVA, the χ2 test, and the Wilcoxon sum rank test to compare study variables. The primary aim was to assess rates of complications from ERCP with SOC in elderly patients compared with younger patients. RESULTS Baseline clinical features were similar among groups, except for a higher prevalence of co‐morbidities in group 3. The indication for and findings from ERCP with SOC differed among the groups; stricture or tumor was the most common indication in groups 1 and 3—the most common findings were strictures and masses, respectively. In group 2, choledocholithiasis was the most common indication and finding. The success rate, analyzed in a subset of 209 patients, was 88.5% overall and did not differ significantly among groups. The overall rate of complication was 7.33% with no significant difference among groups (7.30% for group 1, 6.98% for group 2, and 7.79% for group 3) (P < .17). CONCLUSIONS In a retrospective analysis of ERCPs with SOCs, we found this procedure to be safe for elderly patients (older than 75 years), who had rates of complications and hospital admission similar to those of younger patients.