Factors determining diagnostic yield of endoscopic ultrasound guided fine-needle aspiration for pancreatic cystic lesions: a multicentre Asian study.

BACKGROUND AND AIM: The purpose of this study was to determine (1) the diagnostic yield for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with pancreatic cystic lesions, (2) additional value of EUS-FNA over EUS alone in the diagnosis of pancreatic cysts, and (3) diagnostic sensitivity and specificity of EUS and EUS-FNA in the subset of patients where histopathology of surgical specimens were available. METHODS: All patients who underwent EUS examination for the evaluation of pancreatic cystic lesions in six Asian centres were included in the study. RESULTS: Of 298 patients with pancreatic cysts who underwent EUS, 132 (44.3 %) underwent FNA. In the entire cohort, pseudocysts and intraductal papillary mucinous neoplasm (IPMN) were the predominant cystic lesions. The cytologic yield of EUS-FNA was 47 %. On univariate analysis, factors associated with higher cytologic yield included vascular involvement on EUS, presence of solid cystic component, and increased number of needle passes during EUS-FNA. On multivariate analysis, presence of solid cystic components and increased number of needle passes during EUS-FNA were associated with higher diagnostic yield of EUS-FNA. For pancreatic cysts with a solid component, the diagnostic yield of EUS-FNA increased significantly from 44 % with one pass to 78 % with more than one pass (p = 0.016). In the absence of a solid component, the diagnostic yield was 29 % with one pass and was not significantly different from the diagnostic yield of 50 % with more than one pass, p = 0.081. CONCLUSION: The cytologic yield of EUS-FNA was 47 %. When a solid component was present in the cyst, doing more than one pass during EUS-FNA increased its diagnostic yield.

Endoscopic ultrasound guided fine-needle aspiration of lymph nodes and solid masses: factors influencing the cellularity and adequacy of the aspirate.

GOALS: To study the factors that influence the cellularity and adequacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). BACKGROUND: An on-site cytopathology service is preferred during EUS-guided FNA. However, this is not always available. Factors that influence the aspirate cellularity and adequacy have not been well defined in the absence of on-site cytopathology. STUDY: EUS-guided FNA procedures without an on-site cytopathologist from a single center were retrospectively studied. FNA of solid masses and lymph nodes (LN) were included. The FNA cellularity, hemorrhagic content, and endoscopists' assessment of adequacy were analyzed. RESULTS: A total of 166 patients from January 2009 to October 2010 were included. A total of 520 FNA passes were performed. Of the 166 lesions, 70 (42.2%) were solid masses and 96 (57.8%) were LNs. A 22-G needle was used in 72.3% and 25 G in 27.7% of the patients. The median (range) number of FNA passes was 3 (1 to 7) for LNs and 3 (1 to 5) for solid masses. With this, the endoscopists had an accuracy of 92.2% (153/166) for obtaining an adequate aspirate. Of the 166 samples, 4 (2.4%) were acellular, 20 (12.0%) sparsely cellular, 52 (31.4%) moderately cellular, and 90 (54.2%) highly cellular. The 25-G needle had significantly more adequate aspirates than the 22-G needle for solid masses (P=0.011). Also, increasing passes correlated with higher cellularity (P=0.002) and an adequate aspirate (P=0.021). No correlation was found for LN FNA. Lesion size did not influence the cellularity or adequacy (P>0.05). The degree of hemorrhage was not influenced by the needle gauge, number of passes, or lesion size. The diagnostic yield was not affected by hemorrhage in the sample (P>0.05). CONCLUSIONS: EUS-guided FNA obtains a high proportion of adequate aspirates for LNs and solid masses, even without an on-site cytopathologist. Small proportions of inadequate samples still occur. For solid masses, a 25-G needle with at least 3 passes is more likely to provide an adequate aspirate than a 22-G needle and fewer passes. Hemorrhage did not affect the cytopathology's ability to make a diagnosis.

Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study.

BACKGROUND: Currently available techniques to diagnose indeterminate biliary lesions have many limitations. OBJECTIVE: To assess the accuracy of single-operator peroral cholangioscopy by using the SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions. DESIGN: Prospective, single-arm, single-center study. SETTING: Tertiary referral center. PATIENTS: Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling. INTERVENTIONS: SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies. MAIN OUTCOME MEASUREMENTS: Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions. RESULTS: Thirty-six patients (22 men, mean age 48.3 years [range 27-68 years]) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis. LIMITATIONS: No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures. CONCLUSIONS: SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.

Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound.

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.

Spiral enteroscopy: a preliminary experience in Asian population.

BACKGROUND AND AIM: In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over-tube (Endo-Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients. METHODS: Between January and March 2010, 11 patients underwent spiral enteroscopies. The indication for the procedure was obscure gastrointestinal bleeding in five patients, Crohn's disease in two, malabsorbtion syndrome in two, Peutz-Jeghers syndrome in one and Osler Weber Rendu disease in one patient. RESULTS: Eleven patients (five male and six female) mean age 41.6 years (range 21-62 years) underwent spiral enteroscopy. Spiral enteroscopy advancement was successful in all patients. The average depth of insertion was 249 cm (range 120-400 cm) past the ligament of Treitz, and the average time for the procedure was 27.8 min (range 20-32 min). The findings included ulcers (n = 3), polyps (n = 1), arteriovenous malformation (n = 2), ulcer with stricture (n = 1), and lymphangiectasia (n = 1). No major complications were observed. CONCLUSION: In conclusion, our initial experience with spiral enteroscopy shows that it is easy to perform, takes less time than balloon assisted enteroscopy and is relatively safe.

Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases.

BACKGROUND AND AIM: Single-balloon enteroscopy (SBE) is a novel method of balloon assisted enteroscopy which allows deep intubation of intestine and has therapeutic potential. This prospective study was done in a tertiary care center to evaluate the feasibility, complications, diagnostic and therapeutic yield of SBE in patients with suspected small bowel disorders. METHODS: One hundred and six patients (mean age 40.1 years, range 12-76 years, 65 men) with suspected small bowel diseases underwent 131 SBE procedures between February 2007 and July 2008. RESULTS: Indications for SBE included obscure gastrointestinal bleeding (OGIB) (40), chronic abdominal pain with abnormal imaging studies (34), chronic diarrhea (20), polyposis syndromes (11) and foreign body (1).The mean insertion depth was 255.8 +/- 84.5 cm beyond the duodenojejunal flexure by the oral route and 163 +/- 59.3 cm proximal to the ileocecal valve by the per anal approach. The mean duration of the procedure for antegrade and retrograde enteroscopy was 65.9 +/- 19.5 min and 72.3 +/- 18.3 min, respectively. Pan-enteroscopy was possible in 25% of cases (five of 20 cases in which total enteroscopy was attempted). Diagnostic yields in cases of OGIB, chronic abdominal pain and chronic diarrhea were 60%, 65% and 55%, respectively. Overall new diagnosis was established in 46% and the extent of known disease was assessed in 15% of cases. In 21% of patients, therapeutic interventions were carried out while surgical treatment was directed to 8.4% of the patients. No major complications were observed. CONCLUSION: SBE is well tolerated and has good diagnostic yield, having a similar yield to previous double-balloon enteroscopy reports.

Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: efficacy and analysis of factors that favor stone fragmentation.

BACKGROUND AND AIM: Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study. METHODS: A total of 283 patients with large CBD stones were subjected to ESWL. A maximum of 5000 shocks was delivered per session until CBD stones were fragmented to less than 5 mm diameter. CBD was cleared by biliary endotherapy using a basket or balloon. Outcome was assessed by CBD clearance. RESULTS: Total CBD clearance was achieved in 239 patients (84.4%) and partial CBD clearance in 35 patients (12.3%). Three or fewer sessions of ESWL were required in 74.6% of patients. Minor complications were seen in 45 patients (15.9%). There was no procedure-related mortality. Epidural anesthesia, shock frequency of 90/min, radiolucent calculi and presence of fluid around the calculus helped in better fragmentation. CONCLUSION: A high success rate, negligible complications and non-invasive nature of the procedure make ESWL a useful tool for removing large CBD stones.

Use of a novel transluminal balloon accessotome in transmural drainage of pancreatic pseudocyst (with video).

BACKGROUND: Endoscopic transmural pseudocyst drainage is a multistep procedure. OBJECTIVE: Our purpose was evaluation of a new device, the transluminal balloon accessotome (TBA) in transmural drainage of pancreatic pseudocysts. DESIGN: Case series. SETTING: Subspecialty tertiary care center. PATIENTS AND INTERVENTIONS: Between September and October 2007, all consecutive patients with symptomatic pancreatic pseudocysts in whom TBA was used for pseudocyst drainage were included. Through a therapeutic duodenoscope, the pseudocyst was punctured with the needle-knife of the TBA at the point of maximal bulge. After the cyst cavity was entered, the needle-knife and the handle of the TBA device were withdrawn and a 0.035-inch guidewire was passed into the cavity. The tract was dilated with the inflatable balloon of the TBA device, and a 10F double-pigtail was inserted. RESULTS: Six patients, all male, median age 35 years, underwent transmural pancreatic pseudocyst drainage with TBA during this period. All procedures were completed successfully. There were no major complications during or after the procedure except for fever in 1 patient, which responded to parenteral antibiotics. At 6-week follow-up, the pseudocyst cavity had completely collapsed, and stents could be extracted in all patients. LIMITATIONS: Single-center experience, small sample size. CONCLUSIONS: TBA is a safe, useful, and easy-to-use device for transmural drainage of pancreatic pseudocysts.

Virtual MR pancreatoscopy in the evaluation of the pancreatic duct in chronic pancreatitis.

The main pancreatic duct and the common bile duct can be evaluated with a variety of evolving invasive and non-invasive techniques. Virtual CT pancreatoscopy obtained using special computer software is a recent non-invasive innovation which shows the details of the ductal surface (endoluminal view) with greater precision. The use of special computer software in MRI in order to obtain pancreatic ductal surface details or a virtual MR pancreatoscopy has not been described up to now. We report a short series of four patients suffering from chronic pancreatitis who underwent virtual MR pancreatoscopy with an impact on their management and clinical outcome.

Recurrent acute pancreatitis and Wirsungocele. A case report and review of literature.

CONTEXT: The association of Santorinicele with pancreas divisum has been well described. There is an increased risk of recurrent acute pancreatitis in patients with pancreas divisum who also have Santorinicele. Focal saccular dilation of the terminal part of the main pancreatic duct has been described as an incidental finding and termed, 'Wirsungocele'. CASE REPORT: We report a case of a 39-year-old male who had recurrent episodes of acute pancreatitis. Laboratory tests, US of the abdomen and CECT of the abdomen confirmed acute pancreatitis. MRCP showed focal saccular dilation of the terminal part of the main pancreatic duct suggestive of Wirsungocele. An ERCP confirmed MRCP findings. An endoscopic pancreatic sphincterotomy was performed and a 5 Fr single pigtail pancreatic stent was placed. The pancreatic stent was removed after 4 weeks. At the 12-week follow-up, the patient was asymptomatic. CONCLUSION: This case report describes the association of Wirsungocele with recurrent acute pancreatitis.

Endoscopic ultrasound-guided biliary stent placement using Soehendra stent retriever.

Symptomatic bilary obstruction with duodenal nar-rowing requires either surgical or percutaneous biliary drainage procedure. We report a 54-year-old woman suffering from carcinoma of the head of pancreas, who had combined duodenal and bilary obstruction and underwent successful endoscopic ultrasound-guided transduodenal biliary stent placement.

Role of magnification endoscopy in the diagnosis and evaluation of suspected celiac disease: correlation with histology.

BACKGROUND: Magnification endoscopy (ME), with 115-fold magnification, allows visualization of duodenal villi. We assessed the efficacy of ME for evaluation of villous atrophy. METHODS: ME and duodenal biopsy were done in 16 patients with suspected celiac disease and 16 control subjects undergoing endoscopy for reflux symptoms. The pathologist was unaware of the ME findings. RESULTS: Sensitivity, specificity and positive and negative predictive values for villous atrophy (partial or total) were 100%, 91%, 83% and 100%, respectively. Corresponding values for normal villous structure were 91%, 100%, 100% and 83%, respectively. There was significant concordance between the ME and histology findings. CONCLUSION: ME is a reliable technique to diagnose villous atrophy.

Efficacy of low dose peginterferon alpha-2b with ribavirin on chronic hepatitis C.

AIM: To assess the efficacy of peginterferon alpha 2b at doses of 50 microg weekly and 80 microg weekly (based on body weight) plus ribavirin in HCV genotype 2 and genotype 3 chronic hepatitis C patients. METHODS: During the study period of Jan 2002 to Dec 2003, all patients diagnosed as chronic hepatitis C or HCV related compensated cirrhosis were treated with peginterferon alpha 2b 50 microg S/C weekly (body weight < 60 kg) or 80 microg S/C weekly (body weight > 60 kg) plus ribavirin 800 mg/d for 24 wk. RESULTS: Overall 28 patients, 14 patients in each group (based on body weight) were treated during the period. Out of 28 patients, 75% were genotype 3, 18% were genotype 2 and 7% were genotype 1. The mean dose of peginterferon alpha 2b was 0.91 microg/kg in group 1 and 1.23 microg/kg in group 2 respectively. The end of treatment and sustained virologic response rates were 82% and 78% respectively. Serious adverse effects were seen in 3.5% patients. CONCLUSION: Low dose peginterferon alpha 2b in combination with ribavirin for 24 wk is effective in HCV genotype 2 and 3 chronic hepatitis C patients.

Capsule endoscopy in obscure gastrointestinal bleeding--an Indian experience.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a common indication for capsule endoscopy (CE). Reports on diagnostic yield of CE in this situation show a wide variation. We evaluated the diagnostic yield and clinical impact of CE in patients with OGIB. METHODS: We reviewed the medical records of patients with OGIB who underwent CE at our institution between June 2002 and October 2005. RESULTS: 154 patients (mean age 47 [SD 17] years; 117 men), including 74 with overt OGIB and 80 with occult OGIB, underwent CE. CE yielded positive findings in 57 of 74 patients (77%) with overt OGIB and 22 of 80 (27%) of those with occult OGIB (p < 0.0001); the overall positive diagnostic yield was 52%. NSAID-induced lesions (15%), angiodysplasias (14%) and aphthous ulcers (12%) were the most frequent findings. CE helped in planning further management in 79% of patients with overt OGIB and 26% of those with occult OGIB. CONCLUSION: CE is a useful diagnostic technique in patients with OGIB, especially those with overt OGIB.

Safety of therapeutic ERCP in pregnancy - an Indian experience.

INTRODUCTION: Only limited data are available regarding the safety of therapeutic ERCP in pregnancy. We report our experience with therapeutic ERCP in pregnant women. METHODS: Medical records of 18 pregnant women (first trimester 4, second 6, third 8) who underwent ERCP between July 1994 and December 2004 were reviewed. Patients and their families were contacted to assess the well being of mother and baby. RESULTS: All the women underwent therapeutic ERCP and biliary sphincterotomy for common bile duct (CBD) stones. In 4 patients, 10-Fr CBD stents were inserted; three of these four cases required mechanical lithotripsy after delivery. Median procedure time was 17 min and median fluoroscopy time was 8 seconds. One patient each developed mild post ERCP pancreatitis and post sphincterotomy bleed. One woman had a preterm delivery. At follow up after a median of 6 years, all the babies were healthy. CONCLUSION: Therapeutic ERCP can be performed safely in all the trimesters of pregnancy provided appropriate precautions are taken.

Rome I criteria are more sensitive than Rome II for diagnosis of irritable bowel syndrome in Indian patients.

AIM: To assess the utility and efficacy of Rome I and Rome II criteria for the diagnosis of irritable bowel syndrome (IBS) in India. METHODS: Patients referred with a diagnosis of IBS by general practitioners answered a questionnaire about clinical features, including those listed in the Rome I and Rome II criteria. All patients underwent investigations to determine the cause of their symptoms. Sensitivity, positive predictive value and percent agreement of final diagnosis with Rome I and II criteria were calculated. RESULTS: Among 138 patients studied, 6 patients had organic disease . Amongst 132 patients with functional bowel disease, Rome I criteria diagnosed more patients as IBS than Rome II criteria (110 [83.3%] vs. 41 [31.1%]); 36 patients fulfilled both the criteria. Of the patients positive by Rome I, 32.7% fulfilled Rome II criteria, and of those diagnosed by Rome II criteria, 87.8% fulfilled Rome I criteria. Seventeen patients did not fulfill either Rome I or Rome II criteria, and were classified as functional abdominal bloating, functional diarrhea or functional constipation. CONCLUSION: Rome I criteria are more sensitive than Rome II criteria for the diagnosis of IBS in the Indian population.