Wiriyaporn Ridtitid

Combination of EUS-FNA and elastography (strain ratio) to exclude malignant solid pancreatic lesions: A prospective single-blinded study.

Negative results of EUS‐FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL.

Non-sequential narrow band imaging for targeted biopsy and monitoring of gastric intestinal metaplasia.

AIM To evaluate the efficacy of non-sequential narrow band imaging (NBI) for a better recognition of gastric intestinal metaplasia (GIM). METHODS Previously diagnosed GIM patients underwent targeted biopsy from areas with and without GIM, as indicated by NBI, twice at an interval of 1 year. The authors compared the endoscopic criteria such as light blue crest (LBC), villous pattern (VP), and large long crest (LLC) with standard histology. The results from two surveillance endoscopies were compared with histology results for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio of positive test (LR+). The number of early gastric cancer cases detected was also reported. RESULTS NBI targeted biopsy was performed in 38 and 26 patients during the first and second surveillance endoscopies, respectively. There were 2 early gastric cancers detected in the first endoscopy. No cancer was detected from the second study. Surgical and endoscopic resections were successfully performed in each patient. Sensitivity, specificity, PPV, NPV, and LR+ of all 3 endoscopic criteria during the first/second surveillance were 78.8%/91.3%, 82.5%/89.1%, 72.8%/77.8%, 86.8%/96.1, and 4.51/8.4, respectively. LBC provided the highest LR+ over VP and LLC. CONCLUSION Non-sequential NBI is useful for GIM targeted biopsy. LBC provides the most sensitive reading. However, the optimal duration between two surveillance requires further study.

Cystic pancreatic neuroendocrine tumors: outcomes of preoperative endosonography-guided fine needle aspiration, and recurrence during long-term follow-up.

BACKGROUND AND STUDY AIMS The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and management of cystic pancreatic neuroendocrine tumors (PNETs) is unclear. We aimed to compare clinical/endosonographic characteristics of cystic with solid PNETs, determine diagnostic accuracy of preoperative EUS-FNA, and evaluate recurrence rates after resection. PATIENTS AND METHODS All patients with cystic or solid PNET confirmed by EUS-FNA between 2000 and 2014 were identified. A matched case-control study compared 50 consecutive patients with cystic PNETs with 50 consecutive patients with solid PNETs, matched by gender and age at diagnosis of index cystic PNET. We compared clinical/endosonographic characteristics, assessed diagnostic accuracy of preoperative EUS-FNA for identifying malignancy, and analyzed tumor-free survival of patients with cystic and solid PNETs. RESULTS Cystic PNETs tended to be larger than solid PNETs (mean 26.8 vs. 20.1 mm, P = 0.05), more frequently nonfunctional (96 % vs. 80 %, P = 0.03), and less frequently associated with multiple endocrine neoplasia type 1 (10 % vs. 28 %, P = 0.04). With surgical pathology as reference standard, EUS-FNA accuracies for malignancy of cystic and solid PNETs were 89.3 % and 90 %, respectively; cystic PNETs were less associated with metastatic adenopathy (22 % vs. 42 %, P = 0.03) and liver metastasis (0 % vs. 26 %, P < 0.001). Cystic fluid analysis (n = 13), showed benign cystic PNETs had low carcinoembryonic antigen (CEA), Ki-67 ≤ 2 %, and no loss of heterozygosity. Patients with cystic and solid PNETs had similar recurrence risk up to 5 years after complete resection. CONCLUSIONS Cystic PNETs have distinct clinical and EUS characteristics, but were associated with less aggressive biological behavior compared with solid PNETs. EUS-FNA is accurate for determining malignant potential on preoperative evaluation. Despite complete resection, recurrence is observed up to 5 years following surgery.

The Learning Curve of Gastric Intestinal Metaplasia Interpretation on the Images Obtained by Probe-Based Confocal Laser Endomicroscopy

Background. Reading the results of gastric intestinal metaplasia (GIM) with probe-based confocal laser endomicroscopy (pCLE) by the expert was excellent. There is a lack of study on the learning curve for GIM interpretation. Therefore, we conducted a study to explore the learning curve in the beginners. Material and Method. Five GI fellows who had no experience in GIM interpretation had been trained with a set of 10 pCLE video clips of GIM and non-GIM until they were able to interpret correctly. Then they were asked to interpret another 80 video clips of GIM and non-GIM. The sensitivity, specificity, accuracy, PPV, NPV, and interobserver agreement on each session were analyzed. Results. Within 2 sessions, all beginners can achieve 80% accuracy with substantial to almost perfect level of interobserver agreement. The sensitivities and specificities among all interpreters were not different statistically. Four out of five interpreters can maintain their high quality of reading skill. Conclusion. After a short session of training on GIM interpretation of pCLE images, the beginners can achieve a high level of reading accuracy with at least substantial level of interobserver agreement. Once they achieve the high reading accuracy, almost all can maintain their high quality of reading skill.

Performance characteristics of EUS for locoregional evaluation of ampullary lesions

BACKGROUND The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. OBJECTIVES To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. INTERVENTION EUS. MAIN OUTCOME MEASUREMENTS Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. RESULTS We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. LIMITATION Retrospective design. CONCLUSIONS EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

Prospective comparison of three risk scoring systems in non‐variceal and variceal upper gastrointestinal bleeding

Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre‐endoscopic Rockall scores (PRS) in comparing non‐variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re‐bleeding among patients with non‐variceal and variceal UGIB.

Management of an occluded biliary metallic stent

In patients with a malignant biliary obstruction who require biliary drainage, a self-expandable metallic stent (SEMS) provides longer patency duration than a plastic stent (PS). Nevertheless, a stent occlusion by tumor ingrowth, tumor overgrowth and biliary sludge may develop. There are several methods to manage occluded SEMS. Endoscopic management is the preferred treatment, whereas percutaneous intervention is an alternative approach. Endoscopic treatment involves mechanical cleaning with a balloon and a second stent insertion as stent-in-stent with either PS or SEMS. Technical feasibility, patient survival and cost-effectiveness are important factors that determine the method of re-drainage and stent selection.

The predictors of complications in patients with drug-induced liver injury caused by antimicrobial agents

Aliment Pharmacol Ther 31, 1200–1207

Stent-in-stent through a side hole to prevent biliary metallicstent migration

The covered self-expandable metallic stent (SEMS) has been developed to overcome the problem of tissue in-growth, However, stent migration is a well-known com--plication of covered SEMS placement. Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many ex-perts. Unfortunately, in our case this technique led to an in-cidental upward migration of the SEMS. We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent. This led to a successful pre-ven-tion of stent migration.

Stricture at colorectal anastomosis: to dilate or to incise

tions developed after colectomy, it occurred in up to 22% of patients undergoing colorectal resection [1]. In practice, management of postoperative anastomotic strictures includes endoscopic balloon dilation (EBD), insertion of self-expandable metal stent, repeat surgery, and colostomy. Due to its effectiveness, simplicity, and safety, EBD is always the first choice [2, 3]. Nevertheless, multiple sessions of EBD may be required to achieve long-term patency. Moreover, approximately one-fifth of patients initially managed by EBD required additional treatment, including stent insertion and/or revisional surgery [3]. The failure of EBD may be explained by traumatic injury to the deeper muscle layer from repeated EBD, resulting in formation of cicatrized and contracted new scar tissues [4]. Recently, an endoscopic electrocautery incision (EEI) technique has been reported as an alternative treatment for anastomotic colorectal strictures [5–7]. Radial incisions were performed using either a precut sphincterotome [5, 7] or an insulated tip (IT) knife [6]. However, location, depth and length of the incision in each series were different because these were left to the discretion of the endoscopists. Four case series (n =76) showed good efficacy for EEI in combination with other endoscopic techniques including EBD, adjunctive corticosteroid injection, or Argon plasma coagulation (APC) [8–11]. Furthermore, three studies (n =47) demonstrated the advantage of more aggressive EEI by adding a cutting method after finishing radial incision (RIC), which involves removal of the flaps that developed after radial incisions. In other words, RIC is more like “conization of cervical cancer” [12]. The only difference is that the scar tissue removed by RIC is more cylindrical shaped than cone shaped. In other words, RIC is the technique that “scoops” the deeper fibrotic scar (▶Fig.1a) that may reform again after EBD (▶Fig. 1b) or EEI (▶Fig. 1c). A recent systematic review of 10 studies by Jain et al summarized experience in 186 patients with benign lower gastrointestinal tract anastomotic strictures undergoing EEI, either alone (n = 63) or in combination with another modality (n = 123) [13]. Of those, 47 patients underwent RIC. During long-term follow up, the initial success rates were 95.2%, 95.8%, and 87.8% for EEI alone, RIC, and EEI with EBD, respectively. Recurrent rates of strictures were 4.8%, 0%, and 12.5% for EEI alone, RIC, and EEI with EBD, respectively. Based on these data, stricture recurrence rates in patients undergoing EEI either alone or in combination with RIC were much lower than that previously reported for EBD alone. More interestingly, no recurrent stricture was seen in those who underwent RIC. The advantage of RIC may be due to the technique that can directly excise the scar tissue which could be the cause of refractory stenosis. In this issue of Endoscopy International Open, Asayama et al. demonstrated success in 3 patients undergoing RIC at the level of intraperitoneal colonic anastomotic strictures after failed EBD [14]. Of those, 2 patients had improvement following a single session and the other succeeded after 6 sessions. No procedure-related adverse events or recurrent stricture occurred during a median follow-up of 27 (range 8–37) months. Although this showed the effectiveness and safety of RIC in patients with benign anastomotic strictures, there are certain key issues that have to be addressed in this setting. First, estimation of the length of incision and the depth of cutting to avoid perforation is subject to the endoscopist’s discretion. Second, the learning curve to reach competency in RIC may be steeper because it appears more difficult than conventional EEI. Perhaps endoscopists who are very experienced in endoscopic submucosal dissection (ESD) would be the preferred operators Stricture at colorectal anastomosis: to dilate or to incise