Yousuke Nakai

High single-pass diagnostic yield of a new 25-gauge core biopsy needle for EUS-guided FNA biopsy in solid pancreatic lesions

BACKGROUND Current limitations of EUS-guided FNA include the need for multiple passes and on-site cytology assessment and lack of core specimen. Recently, a new 25-gauge core biopsy needle (PC25) was developed to overcome these limitations. OBJECTIVE To determine the diagnostic yield of EUS-guided FNA aspiration biopsy (FNAB) when using the PC25 needle among patients with solid pancreatic lesions. DESIGN Retrospective analysis. SETTING Academic tertiary referral center. PATIENTS Fifty consecutive patients with a solid pancreatic lesion underwent EUS-guided FNAB with PC25. INTERVENTIONS EUS-guided FNAB with PC25. MAIN OUTCOME MEASUREMENTS The primary outcome was the diagnostic yield in single and overall passes of EUS-guided FNAB when using the PC25 needle for pancreatic solid lesions. RESULTS Cytologic analysis showed malignancy in 38 patients on the first pass, with a cumulative sensitivity of 83%, 91%, and 96% on passes 1, 2, and 3, respectively. Although visible core was reported in 46 patients (92%), histologic core was seen in 16 patients (32%). Histologic analysis showed malignancy in 29 patients on the first pass, with a cumulative sensitivity of 63% and 87% on pass 1 and passes 1 to 4, respectively. The sensitivity, specificity, and accuracy in combined cytologic and histologic results were 85%, 100%, and 86% for single pass and 96%, 100%, and 96% on multiple passes, respectively. No complications were seen. LIMITATIONS A retrospective study design at a single center using a single arm. CONCLUSION EUS-guided FNAB with the PC25 needle showed excellent single-pass and overall diagnostic yields. This needle appears to maintain a high cytologic yield, similar to standard 25-gauge FNA needles, while also providing some histologic core tissue.

Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study.

BACKGROUND The diagnosis of pancreatic cystic neoplasms (PCNs), which now depends on morphology, cytology, and fluid analysis, is still challenging. A novel confocal laser endomicroscopy probe that can be inserted through a 19-gauge FNA needle allows needle-based confocal laser endomicroscopy (nCLE), and the feasibility of nCLE has been reported in PCNs. The combination of cystoscopy by using a through-the-needle fiberoptic probe in combination with nCLE under EUS guidance may improve the diagnosis of PCNs. OBJECTIVE To assess the feasibility, safety, and diagnostic yield of the combination of cystoscopy and nCLE in the clinical diagnosis of PCNs. DESIGN A prospective feasibility study. SETTING An academic tertiary referral center. PATIENTS Thirty patients with PCNs. INTERVENTIONS EUS-guided dual through-the-needle imaging (cystoscopy and nCLE) for PCNs. MAIN OUTCOME MEASUREMENTS Technical feasibility and safety. Associations of cystoscopy and nCLE findings with clinical diagnosis of PCNs. RESULTS The procedure was technically successful with the exception of 1 probe exchange failure. In 2 patients (7%), postprocedure pancreatitis developed. Specific features associated with the clinical diagnosis of mucinous cysts were identified: mucin on cystoscopy and papillary projections and dark rings on nCLE. The sensitivity of cystoscopy was 90% (9/10), and that of nCLE was 80% (8/10), and the combination was 100% (10/10) in 18 high-certainty patients. LIMITATIONS A single-center study and lack of complete pathologic correlation. CONCLUSION The combination of dual through-the-needle imaging (cystoscopy and nCLE) of pancreatic cysts appears to have strong concordance with the clinical diagnosis of PCN. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01447238.).

Newly-developed, forward-viewing echoendoscope: a comparative pilot study to the standard echoendoscope in the imaging of abdominal organs and feasibility of endoscopic ultrasound-guided interventions.

Background and Aim:  Multiple diagnostic and therapeutic endoscopic ultrasound (EUS) procedures have been widely performed using a standard oblique‐viewing (OV) curvilinear array (CLA) echoendoscope. Recently, a new, forward‐viewing (FV) CLA was developed, with the advantages of improved endoscopic viewing and manipulation of devices. However, the FV–CLA echoendoscope has a narrower ultrasound scanning field, and lacks an elevator, which might represent obstacles for clinical use. The aim of this study was to compare the FV–CLA echoendoscope to the OV–CLA echoendoscope for EUS imaging of abdominal organs, and to assess the feasibility of EUS‐guided interventions using the FV–CLA echoendoscope.

Endoscopic Ultrasonography- Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions: A Practical Approach to Diagnosis and Management

The diagnosis and management of pancreatic cystic lesions remains a challenging area in gastroenterology. Differentiating benign from premalignant or premalignant from malignant cysts is complicated by the large overlap in morphologic, chemical, and clinical characteristics. Imaging alone is insufficient to accurately characterize these lesions. Cyst aspiration and fluid analysis has therefore become a major research focus through which our ability to characterize pancreatic cystic lesions has improved, although accuracy is often still lacking. Future work with molecular analysis of cyst fluid, direct cystoscopy, and confocal laser endomicroscopy will likely further enhance the diagnostic accuracy of these lesions.

Endoscopic Ultrasound-Guided Antitumor Agents

The development of linear-array endoscopic ultrasonography (EUS), with its real-time guidance of needle advancement, changed EUS from a diagnostic procedure to an interventional procedure. EUS-guided fine-needle injection (EUS-FNI) is an attractive minimally invasive delivery system with potential applications in local (intratumoral) and combination therapy against esophageal and pancreatic cancers. The evidence of the feasibility of EUS-FNI of antitumor agents has been expanding with promising results.

Successful management of perforation during cystogastrostomy with an esophageal fully covered metallic stent placement

A 49-year-old woman presented for endoscopic treatment of symptomatic pseudocyst refractory to conservative management for the past year. EUS showed a thickwalled 49 39-mm pseudocyst in the pancreatic tail in close opposition to the gastric fundus. The cyst was punctured by using a 19-gauge FNA needle (Fig. 1) followed by guidewire placement and dilation of the fistula with a needle-knife cautery and a 6-mm balloon. Attempted placement of a 10F, 4-cm long double-pigtail stent resulted in dislodgment of the guidewire from the pseudocyst because of extreme angulation of the endoscope required to obtain a satisfactory endoscopic view. The guidewire was re-placed into what appeared to be the pseudocyst cavity under endoscopic control, and balloon dilation was repeated using a 12-mm balloon. Fluoroscopic examination showed possible free air at this point, and thus, the echoendoscope was exchanged for a gastroscope to examine the cystogastrostomy tract. Endoscopy showed a clear perforation next to the true lumen of the cystogastrostomy tract (Fig. 2). We then placed an 18 70-mm esophageal fully covered self-expandable metallic stent (FCMS) (ALIMAXX-ES; Merit Medical Endotek, South Jordan, Utah) by using a stiff guidewire (Savary-Gilliard Wire Guides; Cook Medical Inc, Bloomington, Ind) into the pseudocyst cavity to drain it and to seal the perforation (Fig. 2). Broad-spectrum antibiotics were initiated during the procedure. Abdominal CT after the procedure showed free air and the stent to be in good position (Fig. 3). No pain or other signs of peritonitis developed in the patient, and she was discharged after 48 hours of observation on oral antibiotics. The stent was removed uneventfully 1 month later after repeat CT scan confirmed resolution of the pseudocyst.