Kavous Pakseresht

Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center.

Pancreatic fistula is a known complication of distal pancreatectomy. Endotherapy with pancreatic duct stent placement and pancreatic sphincterotomy has been shown to be effective in its management; however, experience of endotherapy in the management of this complication has not been extensively reported from the United States. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement has also been proposed to prevent this complication after distal pancreatectomy. In our cohort of 59 patients who underwent distal pancreatectomy, 13 (22%) developed a pancreatic fistula in the immediate postoperative period, of whom 8 (14%) patients (5 female, mean age 52 years) were referred for an ERCP because of ongoing symptoms related to the pancreatic fistula. The pancreatic fistula resolved in all patients after a median duration of 62 days from the index ERCP. The median number of ERCPs required to document resolution of the pancreatic fistula was 2. Although a sizeable percentage of patients develop a pancreatic fistula after distal pancreatectomy, only a small percentage of patients require ERCP for management of this complication. Given the high success rate of endotherapy in resolving pancreatic fistula and the fact that the majority of patients who undergo distal pancreatectomy never require an ERCP, performing ERCP for prophylactic pancreatic duct stent prior to distal pancreatectomy might not be necessary.

Mediastinal Schwannoma Diagnosed by Endoscopic Ultrasonography-Guided Fine Needle Aspiration Cytology

Schwannoma is the most common neurogenic tumor that is derived from the peripheral nerve sheath. There are no specific serologic markers or characteristic imaging abnormalities associated with schwannoma. Tissue diagnosis and immunohistochemistry are required to diagnose this lesion. We describe a 65-year-old male with a finding of three mass lesions in the superior and middle mediastinum on computed tomography of the chest. The largest lesion measured 4.6 × 5 cm. The patient subsequently underwent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the lesion and cytology was consistent with spindle cell neoplasm. Immunohistochemical staining of the cytologic specimen was positive for S-100 and negative for pan-cytokeratin, CD34, CD117, calcitonin, smooth muscle actin and desmin. These findings were consistent with schwannoma. This is the second reported case of a mediastinal schwannoma diagnosed by EUS-FNA.

In-class didactic versus self-directed teaching of the probe-based confocal laser endomicroscopy (pCLE) criteria for Barrett's esophagus.

BACKGROUND AND AIMSnOptimal teaching methods for disease recognition using probe-based confocal laser endomicroscopy (pCLE) have not been developed. Our aim was to compare in-class didactic teaching vs. self-directed teaching of Barretts neoplasia diagnosis using pCLE.nnnMETHODSnThis randomized controlled trial was conducted at a tertiary academic center. Study participants with no prior pCLE experience were randomized to in-class didactic (group 1) or self-directed teaching groups (group 2). For group 1, an expert conducted a classroom teaching session using standardized educational material. Participants in group 2 were provided with the same material on an audio PowerPoint. After initial training, all participants graded an initial set of 20 pCLE videos and reviewed correct responses with the expert (group 1) or on audio PowerPoint (group 2). Finally, all participants completed interpretations of a further 40 videos.nnnRESULTSnEighteen trainees (8 medical students, 10 gastroenterology trainees) participated in the study. Overall diagnostic accuracy for neoplasia prediction by pCLE was 77u200a% (95u200a% confidence interval [CI] 74.0u200a%u200a-u200a79.2u200a%); of predictions made with high confidence (53u200a%), the accuracy was 85u200a% (95u200a%CI 81.8u200a%u200a-u200a87.8u200a%). The overall accuracy and interobserver agreement was significantly higher in group 1 than in group 2 for all predictions (80.4u200a% vs. 73u200a%; Pu200a=u200a0.005) and for high confidence predictions (90u200a% vs. 80u200a%; Pu200a<u200a0.001). Following feedback (after the initial 20 videos), the overall accuracy improved from 73u200a% to 79u200a% (Pu200a=u200a0.04), mainly driven by a significant improvement in group 1 (74u200a% to 84u200a%; Pu200a<u200a0.01). Accuracy of prediction significantly improved with time in endoscopy training (72u200a% students, 77u200a% FY1, 82u200a% FY2, and 85u200a% FY3; Pu200a=u200a0.003).nnnCONCLUSIONnFor novice trainees, in-class didactic teaching enables significantly better recognition of the pCLE features of Barretts esophagus than self-directed teaching. The in-class didactic group had a shorter learning curve and were able to achieve 90u200a% accuracy for their high confidence predictions.

Are endoscopic ultrasonography imaging characteristics reliable for the diagnosis of small upper gastrointestinal subepithelial lesions

Purpose of the Study To compare the accuracy of endoscopic ultrasonography (EUS) imaging with histopathology in the diagnosis of upper gastrointestinal subepithelial lesions. Methods Thirty-seven patients (21 female; mean age: 55 y) underwent endoscopic submucosal resection (ESMR) of upper gastro intestinal subepithelial lesions at a tertiary care facility. All patients underwent EUS before ESMR of the lesion. Information regarding location, size, echogenecity, layer of origin, presumptive diagnosis based on EUS imaging, and histopathology diagnosis after ESMR of the subepithelial lesion was recorded. Results Twenty-seven subepithelial lesions were resected from the stomach, 5 from the esophagus, and 5 from the duodenum. The mean size of the lesions was 9 mm (range, 6-18 mm). Thirty-six lesions originated from the submucosa, and 1 from the muscularis propria. Using histopathology as the gold standard, the overall diagnostic accuracy of EUS imaging was 49% (18 out of 37). The accuracy of EUS imaging for the diagnosis of esophageal, gastric, and duodenal subepithelial lesions was 20%, 56%, and 40%, respectively. One patient developed a microperforation, and 1 developed bleeding during the ESMR procedure. No complications were reported with the EUS procedure. Conclusions The diagnostic accuracy of EUS imaging is inferior to histopathology in the diagnosis of small upper gastrointestinal subepithelial lesions. Endoluminal resection is a relatively safe and noninvasive modality that not only provides tissue sample for accurate diagnostic interpretation, but also aids in the complete removal of small subepithelial lesions of the upper gastrointestinal tract.

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice

BACKGROUND & AIMSnIt is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.nnnMETHODSnWe performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs.nnnRESULTSnBy the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET andxa0116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate).nnnCONCLUSIONSnIn this prospective multicenter study, we found that although competence cannotxa0be confirmed for all AETs at the end of training, mostxa0meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms thexa0effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Tu1067 In-Class Didactic vs. Self-Directed Teaching Probe-Based Confocal Laser Endomicroscopy (pCLE) Criteria for Barrett's Esophagus (BE); A Randomized Controlled Trial

Background: With the advent of advanced imaging techniques like pCLE, education and teaching of criteria for disease recognition is critical; however, optimal training methods are unclear. Aim: To compare in-class didactic vs. self-directed teaching in diagnosing dysplastic and non-dysplastic BE using pCLE. Methods: pCLE videos from a previously conducted multicenter trial evaluating the utility of pCLE in BE patients were used for this study. Study participants (gastroenterology fellows and medical students) with no previous pCLE experience were randomized to in-class didactic teaching and self-directed teaching groups

Incidence of Bile Leak After Orthotopic Liver Transplantation and Efficacy of Endoscopic Management-Results From a Tertiary Care Center

Introduction: The natural history of complicated gallbladder disease is recurrent symptoms. Although cholecystectomy is the preferred treatment, previous series have used endoscopically-placed transpapillary gallbladder stents (TGS) to palliate biliary colic and cholecystitis in patients who are not surgical candidates due to their liver disease. We describe outcomes and complications in a large cohort from our transplant center. Methods: A retrospective review was conducted of patients with chronic liver disease who underwent endoscopic retrograde cholangiography with TGS placement for symptomatic gallbladder disease (biliary colic, cholecystitis, gallstone pancreatitis) placed at the University of Michigan between 2005 and 2009. The unit of analysis was the stent placed rather than the patient receiving the stent, considering multiple stents may have been placed in a single patient. This is a more conservative analysis of the complication rate as adverse events may occur after each stent placement. Lab data was collected at baseline before the procedure, within three months post-procedure, and > three months post-procedure. The primary outcome measures were pain relief and complication rate and type. Complications assessed include pancreatitis, infection, stent migration, and perforation. Results: Twenty three gallbladder stents were placed in 18 distinct patients between 2005 and 2009. The mean age of the patients was 50.7 and 7(39%) were female. The mean platelet count was 93.5 k/mm3 and mean INR was 1.5. Mean MELD score was 8.35. Biliary sphincterotomy was not required. Mean time stents were in place was 458.5 days. Nineteen of 23 stents (83%) led to partial or complete resolution of symptoms. Nine of 23 (39%) stents placed were associated with a complication, including four cases of pancreatitis, three cases of bacteremia, and two cases of stent migration. However, this rate was inflated by one patient who had all three of the cases of bacteremia and fever which wasnt clearly due to the stent itself. The cases of pancreatitis were all mild, uncomplicated, and resolved after a few days of hospitalization. Otherwise, there were no cases of bile leak, secondary cholecystitis or bleeding. In 2 patients, stenting led to resolution of symptoms and allowed successful liver transplantation. Although statistical significance was not reached, there was a trend towards a decrease in MELD scores (8.35 before TGS, 6.2 after >3 months), total bilirubin (5.3 mg/dL to 3.3 mg/dL), and INR (1.52 to 1.33). Conclusion: We demonstrate that transpapillary gallbladder stenting is highly efficacious with an acceptable rate of complications in this subset of patients with advanced liver disease and no other option for symptom relief. This approach may provide symptom control allowing definitive therapy with transplantation.