Neville Azzopardi

Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions

BACKGROUNDnCytologic diagnosis by endoscopic ultrasound-guided fine needle aspiration is associated with low sensitivity and adequacy. A newly designed endoscopic ultrasound-guided fine needle biopsy device, endowed with a side fenestration, is now available.nnnAIMSnWe carried out a study with the aim of evaluating the feasibility, safety, and diagnostic yield of the 22-gauge needle with side fenestration for endoscopic ultrasound fine needle aspiration and biopsy of pancreatic cystic lesions.nnnMETHODSn58 patients with 60 pancreatic cystic lesions consecutively referred for endoscopic ultrasound guided-fine needle aspiration were enrolled in a prospective, dual centre study, and underwent fine needle aspiration and biopsy with the 22-gauge needle with side fenestration.nnnRESULTSnFine needle aspiration and biopsy was technically feasible in all cases. In 39/60 (65%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. In lesions with solid components, and in malignant lesions, adequacy was 94.4% (p = 0.0149) and 100% (p = 0.0069), respectively. Samples were adequate for histologic evaluation in 18/39 (46.1%) cases. There were only 2 (3.3%) mild complications.nnnCONCLUSIONSnFine needle aspiration and biopsy with the 22-gauge needle with side fenestration is feasible, and superior to conventional endoscopic ultrasound-guided fine needle aspiration cytology from cystic fluid, particularly in pancreatic cystic lesions with solid component or malignancy, with a higher diagnostic yield and with no increase in complication rate.

Technique of FNA and biopsy by using a needle with side fenestration in pancreatic cystic lesions.

Diagnosis and classification of pancreatic cystic lesionsremain a challenge despite advances in diagnostic tools.Diagnosis is achieved by combining demographic and clin-ical information, radiologic and EUS assessment, intracysticfluid analysis, and cytohistology. Cytology obtained byEUS-guided FNA from cystic fluid has a high specificitybut a low sensitivity because of the small number of cellspresent in the aspirate.Several tools and new techniques have been tried toimprove the adequacy of EUS-guided FNA such as cystbrushing and cystic wall punctures. The efficacy of FNAand biopsy (FNA/B) of the cyst wall by using a 22-gaugeneedle with side fenestration (ProCore Needle, CookEndoscopy, Winston-Salem, NC) was recently reported.In these 2 videos, we show the technique of FNA/B byusing a needle with side fenestration (Video 1, available on-line at www.giejournal.org). Under EUS guidance, thelesion was punctured (Fig. 1A and B), the stylet wasremoved, and suction was applied by using a 10-mL syringeto aspirate all the intracystic liquid. When the cyst wallscollapsed on the needle, aspiration was continued forapproximately 30 seconds to allow cystic wall tissue toenter the side fenestration of the needle (Fig. 1C). Theneedle was moved 3 to 4 times approximately 5 to10 mm back and forth within the lesion and then removed(Fig. 1D).If a solid component is present, FNA/B must be per-formed directly on it.DISCLOSUREAll authors disclosed no financial relationships rele-vant to this publication.

ClearPath: a new method for fast and simple drainage of a perianastomotic abscess.

A-75-year-old man with rectal adenocarcinoma underwent laparoscopic anterior resection with the creation of a protective ileostomy. Endoscopy done 1 month later to assess the possibility of colonic recanalization revealed a fistula adjacent to the colorectal anastomosis, opening into a 5-cm cavity containing a large amount of feces and necrotic material. We were unable to drain the cavity with saline irrigation and suction because of continual blocking of the endoscopic suction channel with necrotic material and feces. Because removing this type of waste material with a Roth Net is very time-consuming, we attempted to apply a new technique to clear the cavity and speed up the procedure. This drainage procedure was carried out with a high definition endoscope (GIFH190; Olympus Medical, Center Valley, Pennsylvania, USA) equippedwith a ClearPath cleaning device (Easy-Glide Ltd., Kfar Truman, Israel) (● Fig.1), which allowed rapid saline irrigation and efficient suction of the necrotic material and feces in the abscess (● Fig.2,● Video 1). Procedure time was about 1 minute, and there were no adverse events. The clean abscess was then successfully treated with vacuum-assisted transanal therapy until complete closure of the cavity. The ClearPath device was developed for rapid luminal irrigation and efficient aspiration through its large suction channel, and allows evacuation of fluids, bile, and blood clots during upper gastrointestinal bleeding while keeping the endoscope working channel free for insertion of therapeutic devices [1]. Use of a ClearPath device during underwater endoscopic mucosal resection has also been reported [2]. Endoscopic drainage of feces and necrotic material from an abscess can be difficult and time-consuming, and possibly entail delay for further therapeutic procedures. Though this is a single report that will require confirmation, it describes a fast and simple drainage method, and illustrates a new, useful, and safe application of this ClearPath device.

ClearPath-assisted underwater endoscopic mucosal resection of a laterally spreading tumor of the colon.

A 50-year-old gentleman with a 4cm laterally spreading tumor of the sigmoid colon was referred to our institute for endoscopic resection. Biopsy of this lesion confirmed the presence of an adenomatous polyp with high-grade dysplasia. Based on the size and histology of the polyp, and in view of its location in the sigmoid colon, we opted to carry out underwater endoscopic mucosal resection (UEMR) [1]. This procedure was carried out with a high-definition narrowband endoscope (GIF-H190; Olympus Medical, Center Valley, PA, USA) equipped with a ClearPath cleaning device (EasyGlide Ltd., Kfar Truman, Israel) to facilitate water irrigation and aspiration during the procedure. With the help of the ClearPath, the colon was rapidly irrigated with water, allowing piecemeal UEMR. All the polyp fragments, regardless of size, were aspirated through the ClearPath suction channel into the central suction canister (● Fig.1,● Fig.2). The patient tolerated the procedure well with no adverse events recorded in the following days. UEMR of large sessile colorectal polyps without submucosal injection was described by Binmoeller et al. in 2012 [1]. In their experience, 60 consecutive patients with large sessile colorectal polyps undergoing UEMR had successful complete resection and no early complications. The ClearPath device has been developed for rapid luminal irrigation with high flow rates and efficient aspiration through its large suction channel (● Fig.2). This may allow evacuation of fluids, bile, and blood clots during upper gastrointestinal bleeding and has also been shown to be useful and safe for cleaning of poorly prepared porcine colon [2]. ClearPath-assisted underwater EMR allowed complete endoscopic resection while reducing procedure time due to fast colonic irrigation/aspiration and rapid polyp fragment retrieval. Although its efficacy cannot be fully demonstrated by a single report, this application of ClearPath appears useful and safe and may stimulate the development and manufacture of new, dedicated devices for UEMR.

Argon plasma coagulation before mechanical fragmentation of a large gastric persimmon bezoar: the woodworm technique

In February 2013, a 74-year-old man with a history of postprandial epigastric pain and nausea underwent esophagogastroduodenoscopy (EGD) at our institute. The patient was a farmer with a longstanding history of persimmon consumption. EGD showed the presence of an ovoid, tough mass with a smooth surface of dark green color in the stomach lumen, with a maximum diameter of about 8cm, suggestive of a persimmon bezoar (● Fig.1a). A 30-mm polypectomy snare (Captivator; Boston Scientific Corp., Natick, Massachusetts, USA) was closed around the bezoar edge and a pull and release movement was applied to obtain a saw-like effect while keeping the bezoar firmly against the endoscope (● Fig.1b). Despite these maneuvers, fragmentation failed. Therefore, a new argon plasma coagulation (APC) approach, which we have named the “woodworm technique,” was utilized. A frontal 2.3-mm APC probe was used (VIO 300D with APC2; Erbe Elektromedizin, Tubingen, Germany) with a gas flow rate of 2.0L/min, at a power setting of 50W. Mimicking woodworm behavior, the APC probe was advanced through the bezoar creating multiple tunnels in order to weaken the structure (● Fig.2). When snared again, the weakened bezoar was successfully ruptured. By repeating the APC-snare sequence, smaller fragments were obtained and crushed with a standard lithotripter to complete bezoar fragmentation (● Fig.3). Patient symptoms improved drastically in the following days. Phytobezoars, the most common type of bezoar, are concretions of poorly digested fruit and vegetable fibers that are found in the alimentary tract [1,2]. A number of surgical, endoscopic, and pharmacological treatments with variable efficacy have been proposed [3,4]. This report describes a new and easy technique for the management of phytobezoars. After failure of standard endoscopic methods, and in order to avoid surgery, the APC “woodworm technique” may be used to create multiple tunnels that weaken the structure of the bezoar and facilitate mechanical fragmentation. Endoscopy_UCTN_Code_TTT_1AO_2AN

Endoscopic guide wire gallbladder decompression in a critically ill, septic patient

A 57-year-old man with postischemic dilated cardiomyopathy underwent a heart transplant at our center in February 2013. His early postoperative course was complicated by primary graft non-function requiring intensive care treatment. Six days after transplantation, he developed severe hypoperfusion that required maximal extracorporeal membrane oxygenation (ECMO), placement of an intraaortic balloon pump, and vasoactive drug support. The patient’s bilirubin level increased from 0.8mg/dL to 7.5mg/dL and his white blood cell (WBC) count from 9×109/L to 37×109/L. Abdominal ultrasound revealed normal-caliber intrahepatic ducts and a 10-cm sludge-filled gallbladder (● Fig.1a). A diagnosis of acute biliary septic shock was suspected and an urgent endoscopic retrograde cholangiopancreatography (ERCP) was requested for gallbladder decompression. A cholangiogram confirmed the normalcaliber intrahepatic ducts and a dilated

Migration of embolization coils placed to stop a severe iatrogenic bleed following endoscopic ultrasound-guided cystogastrostomy

a severe iatrogenic bleed following endoscopic ultrasound-guided cystogastrostomy A 32-year-old man with a large symptomatic pseudocyst was referred for endoscopic ultrasound (EUS)-guided cystogastrostomy. The procedure was complicated by an iatrogenic bleed from the pseudocyst border, which was associated with hypovolemia and a significant drop in hemoglobin. A fully covered self-expandable metal stent (SEMS) inserted between the stomach and the pseudocyst did not stop the bleeding. As a result, transcatheter arterial embolization (TAE) with metal coils was performed by our radiology service (● Fig.1). Hemostasis was achieved immediately after TAE. After 5 days the patient developed fever and pain. A gastroscope was used to inspect the interior of the pseudocyst cavity, and the metal stent was replaced by two pigtail stents. Large blood clots and necrotic material observed in the cyst were removed with a Roth net. During this procedure, two of the metal coils used during TAEwere seen on the border of the cyst at the site of the bleeding; however, two other coils appeared to have migrated directly from the vessel into the pseudocyst cavity (● Fig.2). After the procedure, no further evidence of hemorrhage was recorded. Endoscopic pseudocyst lavage was repeated 4 days later, and the patient was discharged home 2 weeks later. Embolization of selected arteries with metal coils has been previously used to manage iatrogenic EUS-guided cystogastrostomy bleeds [1]. Migration of the coils from the embolized vessels into the gastrointestinal tract is extremely uncommon, with only one documented case of migration of a steel-wire coil into the stomach after arterial embolization [2]. No reports of the migration of metal coils into a pancreatic pseudocyst have been previously reported. TAE appears to be a minimally invasive, highly effective treatment in patients who hemorrhage after cystogastrostomy.

Brush recanalization of a challenging biliary stricture after liver transplantation: a novel application for an old device.

A 34-year-old gentleman, who had undergone orthotopic liver transplantation (OLT) for idiopathic fulminant hepatic failure in November 2004, presented with jaundice andabnormal liver function tests. Magnetic resonance imaging (MRI) identified an anastomotic biliary stricture with dilated intrahepatic ducts, which were also confirmed at endoscopic retrograde cholangiopancreatography (● Fig.1). Although a 0.035-inch hydrophilic guidewire (Acrobat; Cook Medical, WinstonSalem, NC, USA) was passed through the anastomosis, the stricture was not negotiable with standard dilation catheters or with a Soehendra tapered 4F dilator (SBDC-6; Cook Medical) (● Fig.2). As a last resort, “brush recanalization” with an RX-wire-guided cytology brush (Boston Scientific Corp., Natick, MA, USA) was used to treat the stricture. Under endoscopic and fluoroscopic control, the duodenoscope was gently advanced into the duodenum in order to straighten the common bile duct and allow us to orient the brush movements precisely in the direction of the stricture. Surprisingly, the brush advanced successfully through the stricture, possibly due to the stiffness of the brush catheter (● Fig.3). The 8F brush catheter was then pushed through the stricture, resulting in further dilation. Finally an 8cm long, 10mm Niti-S biliary, fully covered, self-expandable metal stent (Taewoong Medical Co. Ltd., Seoul, South Korea) was placed across the stricture to Fig.1 Magnetic resonance image of the anastomotic stricture in a 34-year-old man who had undergone orthotopic liver transplantation.

Endoscopic treatment of an infected retroperitoneal hematoma following endoscopic ultrasound-guided pseudocyst drainage

hematoma following endoscopic ultrasound-guided pseudocyst drainage A 32-year-old man with alcoholic pancreatitis presented with the complaint of abdominal pain and vomiting that necessitated parenteral feeding. Abdominal computed tomography (CT) scan showed a 10-cm pseudocyst in the pancreatic body (● Fig.1) [1]. In view of persisting symptoms and the pseudocyst size, he was referred for endoscopic ultrasound (EUS)-guided cystogastrostomy. Echoendoscopy confirmed the presence of a large pancreatic cyst adherent to the stomach wall. Cystogastrostomy was complicated by spurting of blood from the gastric wall into the pseudocyst cavity. A metal stent was placed across the gastrocystic fistula with initial hemostasis. However, a few minutes later the patient developed hematemesis with a significant drop in hemoglobin. An arteriogram showed active bleeding from a left gastric artery branch (● Fig.2) and transcatheter embolization of this branch was carried out using metal coils. Repeat arteriogram 10 minutes later confirmed successful hemostasis. Prophylactic antibiotics were started. However 5 days later the patient developed high grade fever, and abdominal CT showed a large retroperitoneal hematoma (● Fig.3). We decided to remove the infected clots by using the same technique as for endoscopic necrosectomy. After removal of the metal stent, a gastroscope was passed through the fistula into the retroperitoneal cavity. Blood clots were removed using a Roth Net (● Fig.4) and the cavity was washed with saline. A nasogastric tube was inserted into the cavity and 4-hourly saline lavage was applied through the tube. Another session of endoscopic clot removal was carried out 3 days later, and two double-pigtail catheters (10Fr, 10cm) were inserted into the cavity. CT carried out after the second endoscopy confirmed resolution of the hematoma (● Fig.5), with the patient becoming afebrile soon after that. EUS-guided drainage is the preferred approach for management of pancreatic pseudocyst because of its lower morbidity rate compared with surgical and percutaneous approaches [2]. However, this procedure may be complicated by bleeding [3], and retroperitoneal hematomas arising after bleeding into cyst cavities may become infected. This is the first reported case of management of an infected retroperitoneal hematoma by endoscopic “clot-ectomy.” Fig.3 Abdominal CT shows a large retroperitoneal hematoma. Fig.2 a Metal stent across a gastrocystic fistula, with active bleeding. b Arteriogram showing active bleeding from a left gastric artery branch. Fig.1 Computed tomography (CT) scan showing a 10-cm pancreatic pseudocyst compressing the stomach. Cases and Techniques Library (CTL) E395

The 'clip-band closure' technique: a new endoscopic traction method for closure of a large ulcer.

We present the case of a 69-year-old man with a rectal granular-type laterally spreading tumor (LST) of about 50mm in diameter who underwent endoscopic submucosal dissection (ESD) using a Hybrid knife I-type (Erbe, Tubingen, Germany) at our institute (● Fig.1). The following day, the patient developed rectal bleeding, and endoscopy revealed a large post-ESD ulcer with clots at the base (● Fig.2a). After rinsing the clots, we decided to attempt closure of the ulcer using a new technique, which we called the ‘clip-band closure’ technique. First, a rubber band used for orthodontic treatment (5–6mm in diameter and 56.7–99.2g in strength; ORMCO Corp., Glendora, California, USA) was preloaded onto the open prongs of a Resolution clip (Boston Scientific, Natick, Massachusetts, USA). The clip with the loaded band was inserted through the working channel of the endoscope and attached to the proximal inner margin of the ulcer (● Fig.2b). The band was then clamped again with a second clip, which was pushed towards the opposite mucosal edge distal to the ulcer where it was attached (● Fig.2c). The same clip/band sequence was applied at two other points on the ulcer edge to further draw the ulcer margins together (● Fig.2d). No more episodes of bleeding were recorded in the following days and 1 week later a follow-up endoscopy confirmed closure of the ulcer, with the clips and Fig.1 Endoscopic views of a rectal laterally spreading tumor (LST) in a 69-year-old man: a before endoscopic submucosal dissection (ESD); b,c during ESD.