Submucosal injection fluid and tattoo agents.

BACKGROUND AND AIMS: EMR and endoscopic submucosal dissection (ESD) are minimally invasive endoscopic techniques, developed for the removal of benign and early malignant lesions throughout the GI tract. Submucosal injection of a marking agent can help to identify lesions during surgery. Endoscopic resection frequently involves "lifting" of the lesions by injection of a substance within the submucosal space to create a cushion for safe resection. This review summarizes the current techniques and agents available for endoscopic marking and lifting of GI tract lesions. METHODS: The MEDLINE database was searched through April 2023 for relevant articles related to the lifting and marking aspect of EMR by using key words such as "endoscopy" or "endoscopic" combined with "marking," "tattoo," and "lifting." The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. RESULTS: This technology review describes the techniques for endoscopic tattoo placement and submucosal lifting, along with currently available agents, safety, and costs. CONCLUSIONS: Endoscopists performing EMR and ESD have several choices in submucosal injection materials for lifting and marking agents for tattoos. These may be commercially prepared agents or off-the-shelf materials with or without additives to facilitate visualization. A thorough understanding of the indications, techniques, properties of various agents, costs, and adverse events is necessary in choosing the appropriate materials and technique to optimize lesion resection in EMR and ESD.

Endoscopic ultrasound-guided fine needle aspiration biopsy of the intrapancreatic accessory spleen: a report of 2 cases.

BACKGROUND: Intrapancreatic accessory spleen (IPAS) can pose a challenge in the diagnostic workup by mimicking a pancreatic neoplasm. Reports of IPAS identified by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) are scant in the literature, and increased recognition of this benign entity may reduce misdiagnosis and unnecessary surgical intervention. Here we report 2 cases of IPAS diagnosed by EUS-guided FNA biopsy. CASES: Each patient underwent computed tomographic evaluation for abdominal pain; it revealed a mass or thickening within the tail of the pancreas. Both patients were referred for EUS-guided FNA to further characterize their pancreatic lesions. In both cases, the cytomorphologic appearance of smears and cell blocks demonstrated aggregates of benign splenic tissue characteristic of both white and red pulp. Rare fragments of pancreatic acinar tissue were also identified. One cell block demonstrated benign splenic and pancreatic parenchyma immediately adjacent to one another without an apparent intervening capsule. CONCLUSION: IPAS can be diagnosed by FNA biopsy. Definitive tissue diagnosis in these 2 cases avoided not only unnecessary surgical intervention but also the need for consideration of a "watch and wait" strategy with further imaging and possible additional biopsy attempts.

Therapeutic Endoscopic Ultrasound.

Endoscopic ultrasound (EUS) technology has evolved dramatically over the past 20 years, from being a supplementary diagnostic aid available only in large medical centers to being a core diagnostic and therapeutic tool that is widely available. Although formal recommendations and practice guidelines have not been developed, there are considerable data supporting the use of EUS for its technical accuracy in diagnosing pancreaticobiliary and gastrointestinal pathology. Endosonography is now routine practice not only for pathologic diagnosis and tumor staging but also for drainage of cystic lesions and celiac plexus neurolysis. In this article, we cover the use of EUS in biliary and pancreatic intervention, ablative therapy, enterostomy, and vascular intervention.

Outcome of endoscopic minor papillotomy in patients with symptomatic pancreas divisum.

CONTEXT: Pancreas divisum has been associated with recurrent acute pancreatitis, chronic abdominal pain without elevated pancreatic enzymes, and chronic pancreatitis. Prior studies suggest that endoscopic minor papillotomy benefits certain symptomatic pancreas divisum patients. However, the data are quite limited and there is a lack of long-term follow-up. OBJECTIVE: To describe a retrospective study of endoscopic minor papillotomy for pancreas divisum. PATIENTS: Eighty-nine adult patients who underwent endoscopic minor papillotomy at our referral center were included in the study. Median follow-up was 29 months. INTERVENTION: We conducted a telephone survey. Fifty-three patients were available for the telephone survey. RESULTS: Thirty-two patients (60.4%) reported immediate improvement: however, symptoms recurred in 17 (53.1% of the immediate responders). Repeat endoscopic interventions were performed in 8 patients, with long-term improvement in two. Overall long-term improvement was achieved in 17 patients (32.1%). Results of minor papillotomy were more favorable for patients with recurrent, well-defined bouts of pancreatitis (immediate improvement: P=0.036; long-term improvement: P=0.064) compared to those with pancreatitis who reported continuous pain and those without clinical evidence of pancreatitis (immediate improvement: 73.3%, 42.9% and 44.4%, respectively; long-term improvement: 43.3%, 21.4%, and 11.1%, respectively). CONCLUSIONS: The long-term benefit from endoscopic minor papillotomy using strict criteria is poorer than suggested from previous studies. However, pancreas divisum patients with well-defined bouts of pancreatitis are more likely to benefit from endoscopic minor papillotomy than those without symptom-free intervals between "attacks" and those with pain that is not associated with elevated pancreatic enzymes.

Pancreatitis Secondary to Celiac Trunk Dissection.

Dissection of the visceral arteries happens infrequently, with the superior mesenteric artery being the most commonly affected. Isolated dissection of the celiac trunk is rare, and only a few cases have been reported in the medical literature. We report the case of a 51-year-old male who presented with abdominal pain and was subsequently diagnosed with a celiac trunk dissection with secondary pancreatitis and pancreatic infarction. The patient's symptoms improved with conservative medical management. We review the current literature involving celiac trunk dissection and its management, and provide discussion regarding this unrecognized complication of pancreatitis.