Kenneth F. Binmoeller

Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison.

BACKGROUND The usefulness of currently available colon imaging tests, including air contrast barium enema (ACBE), computed tomographic colonography (CTC), and colonoscopy, to detect colon polyps and cancers is uncertain. We aimed to assess the sensitivity of these three imaging tests. METHODS Patients with faecal occult blood, haematochezia, iron-deficiency anaemia, or a family history of colon cancer underwent three separate colon-imaging studies--ACBE, followed 7-14 days later by CTC and colonoscopy on the same day. The primary outcome was detection of colonic polyps and cancers. Outcomes were assessed by building an aggregate view of the colon, taking into account results of all three tests. FINDINGS 614 patients completed all three imaging tests. When analysed on a per-patient basis, for lesions 10 mm or larger in size (n=63), the sensitivity of ACBE was 48% (95% CI 35-61), CTC 59% (46-71, p=0.1083 for CTC vs ACBE), and colonoscopy 98% (91-100, p<0.0001 for colonoscopy vs CTC). For lesions 6-9 mm in size (n=116), sensitivity was 35% for ACBE (27-45), 51% for CTC (41-60, p=0.0080 for CTC vs ACBE), and 99% for colonoscopy (95-100, p<0.0001 for colonoscopy vs CTC). For lesions of 10 mm or larger in size, the specificity was greater for colonoscopy (0.996) than for either ACBE (0.90) or CTC (0.96) and declined for ACBE and CTC when smaller lesions were considered. INTERPRETATION Colonoscopy was more sensitive than other tests, as currently undertaken, for detection of colonic polyps and cancers. These data have important implications for diagnostic use of colon imaging tests.

Transpapillary and transmural drainage of pancreatic pseudocysts

BACKGROUND Endoscopic drainage of pseudocysts using the transpapillary and transmural approaches has been reported. We evaluated endoscopic drainage in 53 patients with symptomatic pancreatic pseudocysts in whom conservative management had failed. METHODS After preliminary endoscopic retrograde pancreatography, transpapillary drainage was attempted in 33 patients with pseudocysts that communicated with the main pancreatic duct. Transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in the remaining 20 patients and in 4 patients selected for combined transpapillary and transmural drainage. The cause of pseudocysts was chronic pancreatitis in 92%. The median pseudocyst size was 7.0 cm (range, 2 to 16). RESULTS Endoscopic drainage was technically successful in 50 patients (94%), of whom 47 had complete pseudocyst resolution. Complications occurred in 11% and included gallbladder puncture (n = 1) and bleeding (n = 2) after transmural drainage, and pancreatitis (n = 1) after transpapillary drainage; stent clogging resulted in abscess formation in 2 patients. Mean follow-up was 22 months (range, 1 to 70); pseudocysts recurred in 11 patients (23%), of whom 7 were successfully re-treated endoscopically. CONCLUSION Both transpapillary and transmural pseudocyst drainage are highly effective in patients with pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos)

BACKGROUND Tubular plastic and metal stents have inherent shortcomings when used for transenteric drainage of fluid collections. OBJECTIVE To evaluate a novel lumen-apposing, self-expandable metal stent for EUS-guided drainage of pancreatic pseudocysts and the gallbladder. DESIGN Retrospective case series. SETTING Tertiary-care academic medical center. PATIENTS This study involved 15 patients (median age 54 years) with symptomatic pancreatic pseudocysts who underwent 12 transgastric and 3 transduodenal pseudocyst drainage procedures. Five patients (median age 69.5 years) with acute cholecystitis underwent 4 cholecystoduodenostomies and 1 cholecystogastostomy. INTERVENTION Stent deployment under EUS guidance, passage of an endoscope through the stent lumen for pseudocystoscopy or cholecystoscopy, transenteric endoscopy-guided interventions including biopsy, necrosectomy, and stone removal. MAIN OUTCOME MEASUREMENTS Technical and clinical success. RESULTS All stents were successfully deployed without complication, with a median time to removal of 35 days. All pseudocysts resolved after a single drainage procedure. One stent migrated into the stomach, and the remaining 14 were found to be patent at the time of removal. There was no pseudocyst recurrence during the 11.4-month median follow-up period. One gallbladder stent remains indwelling and fully patent at 12 months. Resolution of acute cholecystitis was observed immediately after stent implantation. No recurrence of symptoms was observed during a median follow-up period of 9 months. LIMITATIONS Retrospective study, small sample size, lack of control patients. CONCLUSION Transenteric drainage of pancreatic pseudocysts and the gallbladder by using a novel, lumen-apposing, metal stent was accomplished with high technical and clinical success in this pilot observational study. Further studies are warranted.

Endoscopic snare excision of benign adenomas of the papilla of Vater

Over a 5-year period (1985 to 1990), 25 patients (11 men and 14 women, median age 68) with adenomatous tumors of the papilla of Vater judged to be benign by endoscopic appearance and forceps biopsy were included in this study. All patients had de novo tumors except for two patients who had recurrent adenomas after local surgical excision. Presenting symptoms included pain (19 patients), jaundice (9 patients), and pancreatitis (4 patients). ERCP showed bile and pancreatic duct dilation in 20 patients (6 with stones) and 2 patients, respectively. The adenoma and the papilla of Vater were excised using a standard polypectomy snare (snare papillectomy). Procedure-related complications included bleeding in two patients and acute pancreatitis in three patients. No deaths occurred. Histologic analysis showed benign adenoma with mild to moderate dysplasia in 18 patients and severe dysplasia in 1 patient. Two patients with evidence for intraductal tumor extension on ERCP were referred for surgery. Six patients had recurrences at a median follow-up of 37 months (range, 7 to 79 months), of whom one had intraductal tumor spread and underwent pancreatoduodenectomy. Five patients were re-treated endoscopically; one ultimately required surgery.

Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos)

BACKGROUND The feasibility of single-operator cholangioscopy (SOC) for biliary diagnostic and therapeutic procedures was previously reported. OBJECTIVE To confirm the utility of SOC in more widespread clinical use. DESIGN Prospective clinical cohort study. SETTING Fifteen endoscopy referral centers in the United States and Europe. PATIENTS Two hundred ninety-seven patients requiring evaluation of bile duct disease or biliary stone therapy. INTERVENTIONS SOC examination and, as indicated, SOC-directed stone therapy or forceps biopsy. MAIN OUTCOME MEASUREMENTS Procedural success defined as ability to (1) visualize target lesions and, if indicated, collect biopsy specimens adequate for histological evaluation or (2) visualize biliary stones and initiate fragmentation and removal. RESULTS The overall procedure success rate was 89% (95% CI, 84%-92%). Adequate tissue for histological examination was secured in 88% of 140 patients who underwent biopsy. Overall sensitivity in diagnosing malignancy was 78% for SOC visual impression and 49% for SOC-directed biopsy. Sensitivity was higher (84% and 66%, respectively) for intrinsic bile duct malignancies. Diagnostic SOC procedures altered clinical management in 64% of patients. Procedure success was achieved in 92% of 66 patients with stones and complete stone clearance during the study SOC session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy. LIMITATIONS The study was observational in design with no control group. CONCLUSIONS Evaluation of bile duct disease and biliary stone therapy can be safely performed with a high success rate by using the SOC system.

Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma

A 63-year-old man presented with melena and iron-deficiency anemia. He had a 3-year history of ulcerative colitis involving the rectum and sigmoid colon, for which he was on maintenance Azulfidine therapy. Rectosigmoidoscopy was performed and revealed inactive inflammatory bowel disease. On UGI endoscopy he was found to have a firm, rounded, protruding submucosal tumor, measuring 4 cm, in the fundus (Fig. lA). The tumor had a thick, short stalk and was mobile. No evidence for active gastrointestinal bleeding was observed. Endosonography was performed and revealed a well-circumscribed 3.7 X 3.4 cm submucosal tumor originating from the muscle layer compatible with leiomyoma (Fig. 2). No vascular structures were seen within or in the vicinity of the tumor. No enlarged or pathologic lymph nodes were noted. The tumor was diagnosed as a leiomyoma. Informed consent was obtained for endoscopic removal of the submucosal tumor. Epinephrine (1:20,000, approximately 2 cc) was injected at the base area of attachment as a prophylactic measure to reduce the risk of bleeding. A standard polypectomy snare was used to excise the tumor. After the snare was applied to the base of the tumor, the tumor was transected by applying several seconds of blended current while gradually tightening the snare. The stalk was kept under constant tension by lifting the tumor away from

Single-operator, single-session EUS-guided anterograde cholangiopancreatography in failed ERCP or inaccessible papilla

BACKGROUND ERCP may be challenging or may fail in certain situations, including postsurgical anatomy, periampullary diverticula, ampullary tumor invasion, and high-grade strictures. OBJECTIVE To report a large experience with EUS-guided anterograde cholangiopancreatography (EACP) to facilitate ductal access or perform direct EUS-guided therapy in patients with postsurgical anatomy or failed ERCP. DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Ninety-five consecutive patients with failed ERCP or inaccessible papilla over a 4-year period. INTERVENTIONS EACP techniques involved ductal puncture and ductography, followed by either guidewire advancement for rendezvous ERCP in patients with duodenoscope accessible papilla or direct drainage in altered anatomy. For failures, crossover to the alternate EACP technique was performed when appropriate. MAIN OUTCOME MEASUREMENTS Technical success rates and complications. RESULTS EACP procedures were attempted in 95 of 2566 ERCP procedures (3.7%). EUS-guided cholangiography (n = 70) and pancreatography (n = 25) were successful in 97% and 100%, respectively. EUS-guided rendezvous ERCP was successful in 75% of biliary procedures and in 56% of pancreatic procedures. Direct EUS-guided therapy was successful in 86% and 75% of biliary and pancreatic procedures, respectively. Direct interventions included pancreaticogastrostomy (n = 10), anterograde stent across stricture (n = 10), hepaticogastrostomy (n = 8), and choledochoduodenostomy (n = 1). Ten complications (10.5%) related to EACP or subsequent rendezvous ERCP included pancreatitis (n = 5), hematoma (n = 1), bile leak (n = 1), bacteremia (n = 1), pneumoperitoneum (n = 1), and perforation (n = 1). LIMITATIONS Single-center experience; retrospective study. CONCLUSIONS EACP complements ERCP and allows successful pancreaticobiliary therapy in a large proportion of patients with failed ERCP or difficult-to-access papilla.

Endoscopic ultrasound-guided, 18-gauge, fine needle aspiration biopsy of the pancreas using a 2.8 mm channel convex array echoendoscope

BACKGROUND Previous studies have reported on endoscopic ultrasound-guided, fine needle aspiration biopsy using 22- to 25-gauge needles. We evaluated the histologic and cytologic yield of endoscopic ultrasound-guided, fine needle aspiration biopsy of the pancreas using an 18-gauge, Menghini-type core needle. METHODS Fine needle aspiration biopsy was performed in conjunction with a prototype 2.8 mm channel convex array echoendoscope. The core specimen was placed in formalin for cell block, and residual material was expelled on slides for cytology. Definitive diagnosis was established by surgery or clinical follow-up. RESULTS Of 45 patients who underwent fine needle aspiration biopsy, the needle failed to penetrate indurated pancreatic lesions in five. An average of 2.6 passes were performed in the remaining patients. Sufficient material for a histologic and/or cytologic diagnosis was obtained in 40 patients (histologic and cytologic yield of 68% and 75%, respectively). Combining the results of histology and cytology, the sensitivity and specificity for detection of malignancy was 76% and 100%, respectively. Histology confirmed the cytologic findings in 35 patients, providing additional tissue specific information. In three cases histology established a diagnosis of malignancy where cytology was not conclusively malignant. However, in three cases of surgically confirmed malignancy histology failed to detect malignancy, whereas cytology showed suspicious or malignant cells. The sensitivity of histology and cytology alone in detecting malignancy was 53% and 70%, respectively. Mild pancreatitis occurred after pancreatic fine needle aspiration biopsy in one patient. CONCLUSION Core specimens for histology can be safely obtained using an 18-gauge needle. Histology provides tissue-specific information that complements cytology, but histology is less sensitive than cytology in detecting malignancy.

Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction

Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.

A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans

BACKGROUND N-butyl cyanoacrylate injection has been shown to be effective and safe for the endoscopic treatment of gastric varices. N-butyl cyanoacrylate is not available in the United States, but use of a similar agent, 2-octyl cyanoacrylate, recently was approved for skin closure. This pilot study prospectively evaluated the efficacy and safety of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices. METHODS Twenty-five patients with large gastric fundal varices with either stigmata of recent hemorrhage, a history of bleeding, or high-risk varices underwent intravariceal injection of undiluted 2-octyl cyanoacrylate. The end points for this study were cessation of active bleeding, successful obliteration of visible varices, and prevention of bleeding. RESULTS Within 2 weeks of treatment, 52% of patients had a history of significant variceal bleeding, and 12% had active gastric variceal bleeding at the time of injection. The rate of immediate hemostasis was 100%. Gastric variceal bleeding recurred in 4% of patients (mean follow-up 11 months). The overall mortality rate was 12%; the bleeding-related mortality rate was 4%. CONCLUSIONS Injection of 2-octyl cyanoacrylate appears to be efficacious and safe for both prevention and control of gastric variceal hemorrhage. Larger studies are required to further establish the use of 2-octyl cyanoacrylate for treatment of gastric fundal varices.