Mohammed Barawi

Role of preoperative endoscopic ultrasound-guided fine-needle tattooing of a pancreatic head insulinoma.

Although insulinomas are rare, they are the most common pancreatic neuroendocrine tumor, with an incidence of four cases per million population. Insulinomas are generally benign indolent intrapancreatic tumors. Surgical resection remains the main option for treatment. However, up to 67% of a pancreatic head insulinomas are nonpalpable, thus surgical resection of the nonplapable insulinoma in this area could become problematic resulting in prolonged surgical time, increased risk of pancreatic duct injury and need for pancreaticoduodenectomy. Endoscopic ultrasound-guided fine- needle tattooing (EUS-FNT), has been shown to have a crucial role for localization of pancreatic body and tail lesions, facilitating laparoscopic distal pancreatectomy and helping surgeons identify the location of the tumor. EUS-FNT might have a role for preoperative localization of pancreatic head insulinomas which are likely to be nonpalpable. We report a case of preoperative EUS-FNT for localization of a nonplapable pancreatic head insulinoma. This report demonstrates that EUS-FNT of pancreatic head insulinomas may facilitate surgical resection, reduce operative time and decrease surgical complications.

Endoscopic Treatment of Colonic Duplication Cyst: A Case Report and Review of the Literature

Colonic duplication cysts are a rare congenital abnormality commonly presenting before two years of age. In adults, it has been rarely reported, most often as an incidental finding. We report a case of 42-year-old female complaining of constipation and lower abdominal pain. Patients CT scan of the abdomen showed a cystic lesion at hepatic flexure and the diagnosis was confirmed endoscopically using endoscopic ultrasound (EUS). The cyst was treated employing hot snare to expose the cyst cavity. On our literature search, there have been no reported cases of colonic duplication cyst treated endoscopically. We here discuss incidence, diagnosis, characteristics, and treatment of duplication cysts with special emphasis on endoscopic therapy.

The diagnosis and staging of pancreatic cancer: A comparison of endoscopic ultrasound and Computed Tomography with pancreas protocol

BACKGROUND Pancreatic cancer is the fourth leading cause of cancer-related death in United States. We compared Computed Tomography (CT) with pancreas protocol and Endoscopic Ultrasound (EUS) in terms of mass detection, mass size, vascular involvement and lymph node involvement. METHODS We retrospectively evaluated 93 patients. Concordance between CT and EUS, and accuracy of CT and EUS were assessed using a retrospective chart review and statistical analysis. RESULTS CT and EUS agreed on mass detection in 88% of the cases and mass size in 67% of the cases. They agreed in 74% of cases about the presence or absence of vascular involvement and 82% in lymph node involvement. Cohens kappa indicated that the concordance between two tests was moderately reliable. CONCLUSION CT and EUS agree moderately well in identifying characteristics of pancreatic masses, but discrepancies between the two modalities are common, particularly with respect to involvement of specific blood vessels and lymph nodes. Clinicians should use caution in relying on a single modality to make decisions.

Pancreatic acinar cell carcinoma presenting as a third metachronous primary tumor with unconventional features

Acinar cell carcinoma (ACC) of the pancreas is a rare neoplasm, accounting only 1-2% of pancreatic cancers, and is characterized by exhibiting exocrine differentiation and lacking significant ductal or endocrine differentiation. A diagnostic difficulty exists in that presenting symptoms and conventional radiologic findings in these patients are usually non-specific. Owing to high propensity for vascular and perineural invasion, the majority of the patients with ACC have metastatic disease at presentation, resulting in poor prognosis even after curative surgical resection. A 60-year-old male presented at our institution only complaining of vague left upper quadrant abdominal pain. Notably, his past medical history was significant for thyroid and prostate cancers. Other than slightly elevated serum lipase level (58 U/L), his preoperative laboratory data were unremarkable. Initial computerized tomography (CT) scan revealed a well-defined solitary mass (4 cm × 3.4 cm × 1.7 cm) in the junction of the pancreatic neck and body, which was confirmed by subsequent endoscopic ultrasound (EUS), depicting a 3 cm hypoechoic homogeneous mass. Upon exploration, it was discovered that the tumor had invaded posteriorly into the splenic artery at its origin, splenic vein and portal confluence. Accordingly, the patient underwent distal pancreatectomy and splenectomy with curative intent. The final histopathologic studies on the surgical specimen revealed an uncommon mixed acinar-ductal differentiation pattern. In addition, perineural invasion was noted, while commonly observed angiolymphatic invasion was absent. Contrary to conventional immunohistochemical diagnostic criteria for ACC, the neoplastic cells were immunoreactive with CD10 and negative for keratin. Other than these unusual features, our case fulfilled the immunohistochemical diagnosis of ACC. The American Joint Committee on Cancer (AJCC) pathologic stage determined for this case was T3N0Mx. This case is unique clinically and immunohistochemically. One of the peculiar yet intriguing clinical features was its presenting as a third metachronous primary tumor. Most interestingly, there was no evidence of metastatic disease despite the presence of vascular and perineural invasion, which are thought to influence the disease-free survival and recurrence significantly. Its unconventional staining patterns also made immunochemical diagnosis of this case challenging.

Endoscopic ultrasound assisted resection of duodenal non-ampullary adenomas

Purpose: Non-ampullary duodenal adenomas are rare. There is limited data in the literature regarding endoscopic management. The purpose of the study is to report our own experience with the endoscopic management of such lesions.

A rare complication of ulcerative colitis: an extensive venous thrombosis of major abdominal vessels

Purpose: Introduction: Patients with inflammatory bowel disease have an increased risk of thrombotic events that are multifactorial in nature. It could be secondary to dehydration, thrombocytosis. Protein C and Protein S deficiency, increased Factor VII activity and anticardiolipin Ab levels. Treating thrombotic events during active ulcerative colitis can be troublesome to clinicians due to higher risk of bleeding.

Eosinophilic gastroenteritis in a Columbian female

Purpose: Introduction: Eosinophilic gastroenteritis is a disease entity characterized by infiltration of the gastrointestinal tract with eosinophils. Its etiology is unclear although there are reports of possible food hypersensitivity or other allergic phenomena.

Non contrast spiral computed tomography (SCT) versus endoscopic ultrasound (EUS) for suspected choledocholithiasis and common bile duct dilation: a prospective comparative study

Non contrast spiral computed tomography (SCT) versus endoscopic ultrasound (EUS) for suspected choledocholithiasis and common bile duct dilation: a prospective comparative study

EUS-guided fine needle aspiration (FNA) biopsy utilizing a new disposable 22 gauge FNA needle device: results of diagnostic accuracy and complications from a large prospective single center experience

EUS-guided fine needle aspiration (FNA) biopsy utilizing a new disposable 22 gauge FNA needle device: results of diagnostic accuracy and complications from a large prospective single center experience