Philippe Warzée

25-gauge histology needle versus 22-gauge cytology needle in endoscopic ultrasonography-guided sampling of pancreatic lesions and lymphadenopathy.

Background and study aims: A new 25-gauge (G) endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) device (EchoTip ProCore; Cook Medical, Bloomington, Indiana, USA) has been developed, which features a hollowed-out reverse bevel to trap core samples. However, data on the differences between the diagnostic yield of the 25G EchoTip ProCore and that of a 22G standard needle are limited. Patients and methods: This pilot study included 27 patients referred during an 11-month period for EUS-FNA of pancreatic masses and enlarged lymph nodes adjacent to the upper gastrointestinal tract. Each lesion was punctured once by both a 25G EchoTip ProCore needle and a 22G standard needle (EchoTip; Cook Medical) with capillary sampling. Blinded histocytologic analyses were conducted. The final diagnosis was based on FNA findings of malignant cells, pathologic analysis of the surgical specimen, and/or radiologic and clinical follow-up of at least 7 months. Results: A total of 28 EUS-FNA procedures targeting masses of the pancreas (n = 19) and lymph nodes (n = 9) were performed. No complications were encountered. Single-pass sensitivity rates for pancreatic and lymph node malignancy were equal for the needle types: 89.5 % (95 %CI 66.82 – 98.39) and 66 % (95 %CI 24.1 – 94), respectively. There were no significant differences between the needles in terms of EUS visualization (P = 0.125), amount of blood contamination (P = 0.705), macroscopic quantity of the material (P = 0.858), quality of the cytology (P = 0.438), and adequacy and accuracy of the cell block material (P = 0.220). Conclusions: Both needles were safe and successful in terms of a high diagnostic yield, with similar histocytologic results. The results of this study were presented at Digestive Disease Week (DDW) 2014, Chicago, Illinois. This trial was registered at ClinicalTrials.gov (B027201316271).

Endoscopic Nd:YAG treatment of superficial gastric carcinoma: Experience in 18 western inoperable patients

Endoscopic treatment of superficial gastric cancer has been reported to be effective by many Japanese teams. In this study, the Nd:YAG laser was used to treat superficial gastric carcinoma in inoperable Caucasian patients with the aim of obtaining a complete response, i.e., disappearance of the lesion endoscopically and biopsy specimens negative for cancer. Eighteen patients unsuitable for surgery with various endoscopic patterns of superficial gastric cancer were treated with the Nd:YAG laser. The endoscopic pattern was type I in 4 patients, type II in 10 (5 type IIa, 1 type IIb, 2 type IIc, 2 mixed IIa + IIc), and type III in 4. Staging by echoendoscopy was performed in 11 patients (T1N0). Nd:YAG laser destruction of the gastric tumor was performed in all cases, with a mean of 4.4 laser sessions per patient. Tumor response was assessed by endoscopy and biopsy. Follow-up averaged 33 +/- 23 (SD) months. Five patients died of diseases unrelated to gastric cancer. An initial complete response was obtained in 16 (89%) patients after a mean of 1.7 laser sessions; histologic evidence of cancer persisted in 2 patients during the entire follow-up period. Among patients with an initial complete response, recurrence was observed in 2. One of them was successfully re-treated. At the end of the follow-up period, 14 (77.7%) of the 18 patients had a complete tumoral response; only 4 patients had histologic evidence of cancer. In 3 of these 4 patients, pretherapeutic echoendoscopic staging had not been performed. Among the 14 patients exhibiting a complete response, 3 had negative biopsy results more than 5 years after diagnosis. No complications occurred. In gastric cancer classified as T1N0 on the basis of pretherapeutic echoendoscopy, a high tumor response rate and even 5-year disease-free survival can be obtained with endoscopic Nd:YAG laser treatment. Endoscopic laser destruction thus appears to be a valuable therapeutic alternative to surgery in inoperable patients with superficial gastric cancer.

An easier method for percutaneous endoscopic gastrojejunostomy tube placement

BACKGROUND The current procedures for percutaneous endoscopic gastrojejunostomy (PEG-J) tube placement require fluoroscopy and are time consuming. We describe a new, simple method. METHODS Ten patients had a PEG-J tube placed by the new method. After placement of a percutaneous endoscopic gastrostomy (PEG) tube using standard technique, the PEG tube was pushed up to the pylorus to make it easier to place the jejunal tube into the duodenum without looping in the stomach. Fluoroscopy was not used. The position of the tube was confirmed by a plain x-ray film of the abdomen. RESULTS The mean time required for PEG placement and jejunal tube placement was 9.0 and 8.2 minutes, respectively. In all patients the tip of the jejunal tube was at the ligament of Treitz. In one patient the jejunal tube formed a loop in the duodenum, but this was reduced by spontaneous forward migration. In another patient, the tube migrated back into the stomach after 1 week. CONCLUSION The method described allows easier PEG-J placement without fluoroscopy.

Bile duct adenoma causing recurrent cholangitis: diagnosis and management with targeted Spyglass access and radiofrequency ablation.

A 77-year-old man was admitted for evaluation of recurrent episodes of cholangitis. He had undergone endoscopic retrograde cholangiography (ERC) several times for biliary stone disease and for cholecystectomy, and suffered from advanced Alzheimer disease. Abdominal magnetic resonance imaging (MRI) revealed dilatation of the right posterior intrahepatic duct, with aberrant drainage directly into the common hepatic duct. However, multiple attempts to reach this segment by ERC were unsuccessful. The Spyglass system was then used for selective opacification and optical viewing of the aberrant bile duct (Boston Scientific, Natick, Massachusetts, USA).A reddish nodular lesion was seen obstructing the lumen, and targeted biopsies with a 3-Fr Spybite mini-forceps (Boston Scientific) confirmed the presence of an adenoma. The stricture was dilated with a Hurricane 8-mm, 4-cm balloon (Boston Scientific) and the stones were extracted. The Spyscope was removed and two 7-Fr plastic stents placed. Given the patient’s poor mental and general status, we proposed carrying out endobiliary radiofrequency ablation of the stricture. This was done 4 weeks later with a wire-guided Habib EndoHPB (Emcision, London, UK). This case illustrates the potential impact of selective cholangioscopy with the Spyglass system on diagnosis and management of indeterminate biliary strictures.

Focal autoimmune pancreatitis: role of “modern” endoscopic ultrasound endoscopy?

We read with interest the review by Maillette de Buy Wenniger et al. on the immunoglobulin-G4-associated disease of the pancreas and biliary tree. The authors illustrated in detail the multidisciplinary diagnostic approach of autoimmune pancreatitis (AIP), which combines histology, imaging, serology, other organ (nonpancreatic) involvement, and response to steroid therapy (Mayo HISORt criteria). We would like to comment on the role of new endoscopic ultrasound (EUS) techniques in the diagnosis of focal AIP. Due to the absence of pathognomonic features on standard imaging studies, tissue sampling is generally necessary to firmly establish the diagnosis. However, is tissue sampling sufficient to both exclude malignancy and be specific enough for a diagnosis of AIP? EUS-guided fine-needle aspiration (FNA) has an accuracy of between 85 % and 95 % for cancer diagnosis, with still a significant rate of false-negative results, which indicates the need for repeat EUS – FNA. However, negative cytology or histology obtained by EUS – FNA does not exclude AIP. In order to further investigate these subgroups of patients, the endoscopist possesses two promising imaging tools: real-time EUS elastography of the pancreas and/or contrast-enhanced EUS. Of course, these modalities need state-of-the-art ultrasound systems, and new technology comes with a price tag. Elastographic imaging of pancreatic tumors is usually homogeneous and largely dominated by blue (stiff) areas or strands, with normal elastographic patterns in the remaining parenchyma. Conversely, patients with focal AIP present with a unique pattern of small spotted mainly blue color signals that are evenly spread. In addition, when targeted masses are unclear on fundamental B-mode EUS imaging, elastography may be useful to find the targeted area. Contrast-enhanced EUS using Doppler mode has also proved useful in the discrimination of pancreatic cancer from focal chronic pancreatitis.Focal AIP presents a net-like hypervascularization pattern after contrast agent injection. Conversely, color and power Doppler demonstrate a relatively hypovascular pattern in pancreatic adenocarcinoma compared with the remaining pancreas parenchyma, with a sensitivity and specificity comparable to cytopathology. We believe therefore that EUS elastography and contrast-enhanced EUS alone or in combination are promising tools in the diagnostic approach of focal AIP. Although, they may be considered as “toys” by some experts, it seems that in the near future their use might be integrated in the diagnostic algorithms of AIP.

Expanding the horizons of endoscopic ultrasound: diagnosis of non-digestive pathologies

Endoscopic ultrasound (EUS) is mainly used for the evaluation and sampling of mediastinal and abdominal lymph nodes, luminal and submucosal lesions of the upper and lower gastrointestinal tract, as well as in the diagnostic approach for pancreatic, biliary and liver disease. However, several non-digestive pathologies may be encountered as well, expanding the diagnostic potential of EUS. In this article, we present nine examples of extra-digestive abnormalities detected by means of EUS, including pathologies of the thyroid gland, mediastinal and abdominal vessels, lungs, kidney and the urinary bladder. The purpose of this article is to review the capabilities of EUS beyond routine evaluation of gastrointestinal organs.

Single operator endoscopic ultrasound-assisted rendezvous for the treatment of pancreaticocutaneous fistula.

Fig. 2. Fluoroscopic view of the deployed pancreatic stent. Endoscopic ultrasound (EUS)-guided rendezvous technique for pancreatic duct (PD) access has been described in several case series, with a success rate between 25 and 90% [1–6], including 4 patients with post-Whipple fistula [3,4,6]. However, the rendezvous was technically feasible in only two cases [3]. Hereby we present a case of successful management of a pancreaticocutaneous fistula with the rendezvous technique. A 50-year-old woman was referred for management of a pancreatic fistula, secondary to a surgical biopsy of an adenocarcinoma of the head of the pancreas A pancreatic stent placement was scheduled. However, selective access of the PD through the major papilla was technically difficult due to a previously deployed biliary uncovered self-expandable metal stent. In addition, access through the minor papilla, as well as through the fistula failed. For this reason an EUS-assisted rendezvous technique was attempted. The PD was punctured through the stomach with a linear array echoendoscope (Olympus, Belgium) and a 19-gauge needle (Boston Scientific, Belgium). Contrast medium injection confirmed correct positioning in the PD. Then a 0.025-inch guidewire (VisiGlide, Olympus) was advanced through the needle. After several unsuccessful attempts to advance the guidewire through the malignant stricture, it finally reached the duodenum through the minor papilla (Fig. 1). The echoendoscope was removed over the guidewire, and a duodenoscopewas inserted. The distal end of the guidewire exiting through the minor papilla was grasped with a snare and was withdrawnwith the endoscope from the mouth as a single