Petros C. Benias

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Initial experience with a novel EUS-guided core biopsy needle (SharkCore): results of a large North American multicenter study.

Background and aims: The ability to safely and effectively obtain sufficient tissue for pathologic evaluation by using endoscopic ultrasound (EUS) guidance remains a challenge. Novel designs in EUS needles may provide for improved ability to obtain such core biopsies. The aim of this study was to evaluate the diagnostic yield of core biopsy specimens obtained using a novel EUS needle specifically designed to obtain core biopsies. Patients and methods: Multicenter retrospective review of all EUS-guided fine-needle biopsies obtained using a novel biopsy needle (SharkCore FNB needle, Medtronic, Dublin, Ireland). Data regarding patient demographics, lesion type/location, technical parameters, and diagnostic yield was obtained. Results: A total of 250 lesions were biopsied in 226 patients (Median age 66 years; 113 (50 %) male). Median size of all lesions (mm): 26 (2 – 150). Overall, a cytologic diagnosis was rendered in 81 % specimens with a median number of 3 passes. When rapid onsite cytologic evaluation (ROSE) was used, cytologic diagnostic yield was 126/149 (85 %) with a median number of 3 passes; without ROSE, cytologic diagnostic yield was 31/45 (69 %, P = 0.03) with a median number of 3 passes. Overall, a pathologic diagnosis was rendered in 130/147 (88 %) specimens with a median number of 2 passes. Pathologic diagnostic yield for specific lesion types: pancreas 70/81 (86 %), subepithelial lesion 13/15 (87 %), lymph node 26/28 (93 %). Ten patients (10/226, 4 %) experienced adverse events: 4 acute pancreatitis, 5 pain, 1 fever/cholangitis. Conclusions: Initial experience with a novel EUS core biopsy needle demonstrates excellent pathologic diagnostic yield with a minimum number of passes.

Gastric Peroral Endoscopic Pyloromyotomy Therapy for Refractory Gastroparesis

Opinion statementPurpose of review Gastroparesis is a complex dysmotility disorder in which a number of normal gastric emptying mechanisms can be affected. The pylorus as an apparatus is particularly important since it stands as the last final gateway for gastric emptying. As such, pyloric interventions seem to be successful in reducing symptoms and also improving emptying of solids, an effect not observed with other medical interventions. Recent findings Gastric peroral endoscopic myotomy (G-POEM) is a novel technique which offers the promise of mimicking the success of a traditional surgical pyloroplasty, while embracing the minimally invasive paradigm of flexible endoscopic surgery. Emerging data seems to suggest that not only does G-POEM offer symptomatic and clinical improvement but also objective improvement in follow-up gastric emptying studies in as much as 70% of patients. Summary We believe that with proper patient selection, G-POEM will become a powerful tool for gastroenterologists managing this chronic debilitating disease.

Endoscopic Myotomy for Foregut Motility Disorders

Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure classically performed for the treatment of achalasia. The procedure is based on principles of submucosal endoscopy and is composed of a mucosal incision, submucosal tunneling, myotomy, and mucosal closure. Multiple published studies that collectively include more than 6000 patients reported clinical success in more than 80% to 90% of patients. Recent literature also suggested durability of response over a medium-term follow-up. POEM is associated with a low rate of adverse events when performed by experienced operators. Gastroesophageal reflux is not infrequent after POEM but does not seem significantly different from reflux that occurs after Heller myotomy. POEM also seems to be effective in the treatment of spastic esophageal disorders (eg, jackhammer and diffuse esophageal spasm). Last, the role of gastric POEM (G-POEM) in the treatment of gastroparesis has been investigated in recent studies with promising results.

Initial experience with a novel resection and plication (RAP) method for acid reflux: a pilot study

Background and study aims  Current endoscopic therapies for gastroesophageal reflux disorder (GERD) are limited by technical complexity, and/or cost. We sought to evaluate the success of a novel resection and plication (RAP) anti-reflux procedure. Patients and methods  RAP was performed on 10 patients with GERD refractory to proton pump inhibitor (PPI) therapy. RAP consists of semi-circumferential mucosectomy along with full-thickness plication of the lower esophageal sphincter (LES) and cardia. We assessed the technical success and safety as well as followed GERD-Health Related Quality of Life (GERD-HRQL) scores and medication usage. Results  All patients underwent RAP without adverse events and were discharged on the same day. Only half of the patients required general anesthesia. Follow-up ranged from 5 to 24 months (median 9 months) and all patients had a significant improvement in their GERD-HRQL scores ( P  < 0.0001, 95 % CI 19.3 – 25.3). 8 of 10 eliminated their daily PPI dependence. Conclusions  The RAP method has potential as an effective anti-reflux option. Its main advantages include a short procedure time, simple approach using readily available equipment, and possible avoidance of general anesthesia.

Percutaneous endoscopic necrosectomy

A 32-year-old man presented to our institution with abdominal pain, anorexia, fevers, and leukocytosis from a large walled-off necrosis. Prior to this presentation he had been admitted to a local hospital 6 weeks previously with acute severe alcohol-related pancreatitis, which entailed a prolonged stay in the intensive care unit due to multiorgan failure. He was found to have an abdominal fluid collection during this admission for which a percutaneous drain had been placed. An endoscopic cystogastrostomy was performed using a lumen-apposing covered metal stent, with subsequent endoscopic necrosectomies. However, he continued to have persistent systemic inflammatory signs from a large persistent collection in the right upper quadrant of the abdomen with inflammatory stranding. A previously placed percutaneous drain proved to be insufficient for what was mostly solid necrosis. A multidisciplinary decision to perform a percutaneous endoscopic necrosectomy was made. A 10cm×18mm fully covered metal stent was placed in the track of the percutaneous catheter under fluoroscopic guidance to dilate the track. This was followed, the next day, by a singlesession debridement of the cavity which subsequently resulted in significant clinical improvement and the patient’s eventual discharge from the hospital. Complete healing of the fistula track and removal of all external drains was achieved in 4 weeks. The lumen-apposing stent was successfully removed 2 months after placement. Necrotizing pancreatitis and infected necrotic tissue is associated with a high rate of morbidity and mortality. While about a third of patients with infected necrosis may respond to percutaneous catheter drainage, the majority tend to require debridement [1]. This has led to the evolution from a morbid open surgical debridement to minimally invasive techniques including the percutaneous flexible endoscopic approach. Two small series have shown this technique to be effective [2, 3]. Complications included a case of pancreaticocutaneous fistula in each series and self-limited bleeding in one series. Percutaneous endoscopic necrosectomy is an effective adjunct to the management of necrotic pancreatic collections and may especially be considered when percutaneous access has already been achieved by means of a traditional drain.

Band Erosion: Surgical and Endoscopic Management

Erosions of adjustable gastric bands have become uncommon. The presentation of an erosion is insidious with a clinical course characterized by weight gain and loss of restriction and rarely by significant hematemesis. Upper endoscopy is the preferred diagnostic tool. Surgical explantation remains the preferred option with endoscopic explantation in selected patients. Staged band replacement allows resumption of weight loss with a low risk of re-erosion, while conversion to sleeve gastrectomy or gastric bypass results in effective weight loss. A staged approach may improve morbidity associated with the latter options.

Use of volumetric laser endomicroscopy for determining candidates for endoscopic therapy in superficial esophageal squamous cell carcinoma

Background Accurate staging of superficial esophageal squamous cell cancer (ESCC) for endoscopic therapy is challenging. Optical coherence tomography (OCT) has been shown to be superior to high-resolution endoscopic ultrasound (EUS). Volumetric Laser Endomicroscopy (VLE), a second-generation OCT, has recently become commercially available. Objective To assess if VLE can determine which patients with superficial ESSC can undergo endoscopic therapy. Methods This is a multi-center retrospective study. Patients were included if (a) they had visible ESCC, (b) they underwent VLE and EUS for staging, and c) if superficial disease was suspected then endoscopic resection had to be performed to have accurate histology to compare the VLE scan to. VLE scans were then compared to the gold standard: histology for superficial disease and EUS for disease T1b and greater. Results Seventeen patients were included with the following disease: squamous intraepithelial neoplasia (4 patients), T1a disease (6 patients), T1b (2 patients), T2 disease (2 patients) and T3 disease (3 patients). VLE was able to distinguish superficial disease, defined as disease limited up to the lamina propria, from non-superficial disease in all cases. Conclusions VLE may be able to determine which ESCC patients are candidates for endoscopic therapy. Prospective studies are needed to confirm this.

Author Correction: Structure and Distribution of an Unrecognized Interstitium in Human Tissues

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Digital pancreatoscopy in the evaluation of main duct intraductal papillary mucinous neoplasm: a multicenter study

BACKGROUND The aim of this study was to investigate the outcomes of digital pancreatoscopy in main duct intraductal papillary mucinous neoplasm (MD-IPMN). METHODS This was a multicenter retrospective study. Outcomes analyzed were safety, incremental pathology yield compared with previous cross-sectional/endoscopic ultrasound (EUS) imaging, and whether the surgical procedure was dictated by the pancreatoscopy. RESULTS A total of 31 patients were enrolled from six tertiary care centers. Overall, 42 % of cases had findings on pancreatoscopy that were not seen on cross-sectional imaging or EUS. Digital pancreatoscopy dictated the type of surgery performed in 13 patients (42 %) who underwent surgery. However, in patients with a diffusely dilated pancreatic duct (> 10 mm), the pancreatoscopy dictated the type of surgery in 77 % of cases vs. 17 % of cases in the focally dilated pancreatic duct group (10/13 vs. 3/18; P = 0.001). CONCLUSION Digital pancreatoscopy should be considered in the diagnostic algorithm of MD-IPMN in patients with a diffusely dilated pancreatic duct and without any focal lesions seen on cross-sectional imaging or EUS.