Fine-needle biopsy is superior to fine-needle aspiration of suspected gastrointestinal stromal tumors: a large multicenter study.

Background and study aims There are numerous studies published on the diagnostic yield of the new fine-needle biopsy (FNB) needles in pancreas masses. However, there are limited studies in suspected gastrointestinal stromal tumors (GIST lesions). The aim of this study was to evaluate the diagnostic yield of a new fork-tip FNB needle. Patients and methods This was a multicenter retrospective study of consecutive patients from prospectively maintained databases comparing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) versus endoscopic ultrasound-guided FNB (EUS-FNB) using the fork-tip needle. Outcomes measured were cytopathology yield (ability to obtain tissue for analysis of cytology), ability to analyze the tissue for immunohistochemistry (IHC yield), and diagnostic yield (ability to provide a definitive diagnosis). Results A total of 147 patients were included in the study of which 101 underwent EUS-FNB and 46 patients underwent EUS-FNA. Median lesion size in each group was similar (21 mm vs 25 mm, P  = 0.25). Cytopathology yield, IHC yield, and diagnostic yield were 92 % vs 46 % ( P  = 0.001), 89 % vs 41 % ( P  = 0.001), and 89 % vs 37 % ( P  = 0.001) between the FNB and FNA groups, respectively. Median number of passes was the same between the two groups at 3.5. Conclusion EUS-FNB is superior to EUS-FNA for diagnostic yield of suspected GIST lesions. This should be confirmed with a prospective study.

Safety and feasibility of performing peroral endoscopic myotomy as an outpatient procedure with same-day discharge.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) has emerged as a promising treatment option for achalasia and other foregut dysmotility disorders. However, much of the current postprocedural care, such as mandatory admission and routine esophagrams, has been adapted from current surgical practices and may not in fact be necessary. Here, we describe our algorithm and outcomes for same-day discharge. METHODS: Outcomes of 103 consecutive patients who underwent POEM for achalasia and other foregut dysmotility disorders from January 2015 to December 2018 were analyzed. Patients were discharged on the same day without esophagrams following a predetermined algorithm based on procedural adverse events and postprocedural pain. Patients were closely monitored after discharge for adverse events at 24 and 48 hours and then routinely in the office setting. RESULTS: Of the 103 POEMs, 101 were completed successfully. A total of 62.4% of patients were discharged safely on the same day, 29.7% were admitted for mild pain, and 7.9% were admitted for observation for other reasons. Overall, there were no serious adverse events at any time point. Univariate analysis identified duration of disease greater than 3 years, longer length of procedure (50.9 vs 68.5 min, P < .0001), and longer length of myotomy (7.2 vs 8.5 cm, P < .0068) as significant factors associated with postprocedural pain requiring admission. CONCLUSIONS: Although same-day discharge and foregoing routine esophagram have been suggested by many, this routine has not been systematically implemented. This series suggests that an algorithm for same-day discharge based on postprocedure chest pain and procedural complexity is both safe and feasible.

Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort.

BACKGROUND & AIMS: Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS: We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS: Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION: In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.

The role of transjugular intrahepatic portosystemic shunt in the management of portal vein thrombosis: a systematic review and meta-analysis.

BACKGROUND: The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal vein thrombosis (PVT) remains controversial. This study aimed to conduct a systematic review and meta-analysis to evaluate the role of TIPS for the management of PVT in adult patients with liver disease. PATIENTS AND METHODS: Multiple databases were searched through April 2017. Data were gathered to estimate the rates of technical success, portal vein recanalization, portal patency, hepatic encephalopathy, and mean change in portal pressure gradient in patients with PVT who underwent TIPS. Estimates were pooled across studies using the random effects model. RESULTS: Eighteen studies were included in the analysis. The pooled technical success rate was 86.7% [95% confidence interval (CI)=78.6-92.1%]. Rate of portal vein recanalization was 84.4% (95% CI=78.4-89.0%). The rate of complete recanalization was 73.7% (95% CI=64.3-81.3%). Portal patency was 86.9% (95% CI=79.7-91.8%). Mean change in portal pressure gradient was 14.5 mmHg (95% CI=11.3-17.7 mmHg). Hepatic encephalopathy was 25.3% (95% CI=19.2-32.6%). The number of major adverse events reported across studies was low. The majority of the analyses were not associated with substantial heterogeneity. CONCLUSION: The use of TIPS in the management of PVT is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications. TIPS should be considered as a viable treatment option in patients with PVT. Given the limited amount of randomized comparative studies reported, additional trials are warranted to assess the safety and efficacy of TIPS as a treatment modality in PVT, in comparison to other treatment options, such as anticoagulation.

Rare Metastasis of Primary Pancreatic Adenocarcinoma to the Bladder.

Pancreatic cancer commonly metastasizes to the liver, lungs, stomach, bone, and bowel, but rarely does it spread to the bladder. We describe a case of a 66-year-old woman with diabetes mellitus who presented with abnormal liver function laboratory tests, abdominal discomfort, unintentional weight loss, and no urinary symptoms. Abdominal CT revealed a pancreatic and bladder mass. Pathology of the bladder mass confirmed metastatic adenocarcinoma of pancreaticobiliary origin. To our knowledge, this is only the third case of metastatic pancreatic cancer spreading to the bladder since 1953.

The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis.

BACKGROUND AND STUDY AIMS: Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC. PATIENTS AND METHODS: Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger's test. RESULTS: A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % - 91 %). The accuracy of POC was 89 % (95 %CI 84 % - 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % - 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % - 9 %). CONCLUSIONS: POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.

Biliary Obstruction After Transjugular Intrahepatic Portosystemic Shunt Placement in a Patient With Budd-Chiari Syndrome.

A 20-year-old male presented with 2 months of progressive abdominal distension due to ascites and Budd-Chiari syndrome. He underwent transjugular intrahepatic portosystemic shunt (TIPS) placement, but soon after had elevated liver enzymes. MRCP revealed mild left intrahepatic biliary dilatation without stones or obvious stricture. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a focal stricture due to compression by the TIPS. The stricture was dilated and a 10 Fr x 15-cm plastic stent was placed with excellent biliary drainage. The patient's symptoms and liver tests normalized within 1 week. This is the first case of biliary obstruction due to TIPS placement effectively managed by ERCP.