Solid pancreatic lesions: The choice of fine-needle aspiration-needle to optimize the diagnosis.

INTRODUCTION: Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (FNA) have a better accuracy for the detection of pancreatic tumors compared with others images modalities. We assessed if the image criteria of elastography and contrast harmonic echo-endoscopic ultrasound could help in choosing the appropriate FNA-needle in the evaluation of focal pancreatic mass in other to maximize the diagnostic yield. This study prospectively included all new patients with focal pancreatic masses referred to be examined by EUS from October to December/2013. A total of 21 patients performed EUS with sequentially elastography and intravenous injection of a second-generation contrast agent (2.4 mL of SonoVue, Braco International, The Netherlands). The lesions which appear hipovascular were assessed with 22 gauge or 25 gauge FNA-needles. The hipervascular masses were biopsied with 19 gauge needles. RESULTS: The topography of the lesions varied on 13 at the head, 4 at the body and 1 on the tail. The finding of a hypoenhanced mass was found in 57% (12/21 patients). Hyperenhanced was detected in 28% (6/21 patients). There were 14% (three patients) which the data were not recorded. The cytological diagnosis was achieved in 81% (17/21 patients) on the first biopsy. The others four patients have reached the diagnosis on the second examination. Of those four patients, in one was used the ProCore 25 gauge (lesion on the uncinatus process), and another one was used both 22 gauge and 25 gauge in the first examination. CONCLUSION: A characterization of the pancreatic lesions with elastography and contrast agents might be useful for clinical decision of which needle is better to improve biopsy quality and minimize EUS-FNA negatives results.

Short-term results after hepaticogastrostomy guided by echo-endoscopy: Monocentric retrospective study.

BACKGROUND: Biliary drainage guided by echo-endoscopy (EUS) is a recent technique but expanding more and more in addition of retrograde and percutaneous approaches. METHODS: Seventy-three hepaticogastrostomy (HG) were carried out from 2000 to 2013. After exclusion of patients included in a randomized prospective study, data from 60 patients were retrospectively analyzed in order to study the feasibility and early results of this technique. RESULTS: During the study period, 60 patients (woman = 32; median age = 64 years [38-93]) were treated by HG. This technique was choose in the event of impossibility to reach the papilla, a failure of endoscopic retrograde cholangiopancreatography or to achieve drainage of the left hepatic biliary ducts in 35%, 15% and 50%, respectively. The biliary stricture was neoplasic in 85%. Sixty-four procedures were carried out: The technical success rate was 94%. Eighteen patients presented one or more adverse effects (28%) including: Infection (n = 14), pneumoperitoneum (n = 7), choleperitoneum/bilioma (n = 8), hemorrhage (n = 2), other (n = 2). Seven stents migration occurred (11%). The average duration of hospitalization was 9 days (0-61j). Three related deaths occurred, due to severe infection. During the period of the study, several types of stent were placed during the first procedure: Plastic stent (n = 12), one covered or uncovered metallic stent (n = 9), association of one uncovered metallic stent and one fully covered stent (SIS, n = 27), or one half covered metallic stent (n = 16). The rate of complications was respectively 33% (n = 4), 56% (n = 5), 26% (n = 7) and 13% (n = 2) according to the type of stent used. Three successive periods can thus be individualized according to the type of biliary stent used and the use of the CO2 insufflator [Table 1]. [Table: see text]. CONCLUSIONS: Hepaticogastric anastomosis guided by echo-endoscopy is an effective, useful technique when the retrograde way is not possible or to drain selectively left intrahepatic biliary ducts. The morbidity rate is quite high but seems to decrease.

Endoscopic ultrasonography-guided bi-lateral biliary drainage: A case series study.

INTRODUCTION: Biliary obstruction is preferentially managed by endoscopic retrograde cholangiopancreatography (ERCP). However, after ERCP failed, alternatives include percutaneous transhepatic drainage, surgery and more recently, endoscopic ultrasonography (EUS)-guided hepaticogastrostomy. The limitation of this technique is that the drainage is restricted to the left side. The aim of this study is to describe a new method of drainage of both hepatic ductal systems by hepaticogastrostomy in patients with hilar obstruction. RESULTS: Nine prospectively patients were included, all with hilar obstruction (metastasis of a pancreatic adenocarcinoma n = 4, cholangiocarcinoma n = 1, gallbladder cancer n = 2 and metastasis from a pancreatic neuroendocrine tumor n = 2). A total of four patients had previously Whipple surgery and the others five had duodenal involvement by the tumor. The topography of the stenosis varied from Bismuth type 2 (n = 7) and hilar infiltration in the others two. All of them were submitted a three-step drainage. The first one consisted in a transgastric EUS-guided puncture of the left-side bile duct with a 19 gauge needle, insertion of a 0.0035 inch guide wire which was positioned at the right biliary tree crossing the bile bifurcation. After a dilatation with 6 Fr cystotome, a non-covered self-expandable metal stent was placed communicating the right and left biliary ducts. Finally, a second stent, partially covered, was inserted at the left biliary duct, with the distal part inside the previously stent and the proximal edge positioned at the stomach. Successful drainage was observed in seven patients, two of them presented abdominal pain during the first 72 h. One patient developed sepsis and death 7 days after the procedure and the other one had drainage failure. Jaundice was reduced significatively in seven patients and a chemotherapy was started in 6/7 patients. CONCLUSION: This pilot study shows the feasibility of this new technique to drain the right biliary duct in patients with hilar obstruction, with few major complications rates.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration.

OBJECTIVE: Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma. MATERIALS AND METHODS: Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France. RESULTS: A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma. CONCLUSION: EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Radiofrequency ablation associated to mucosal resection in the oesophagus: experience in a single centre.

UNLABELLED: Endoscopic resection (EMR) and radiofrequency ablation (RFA) form part of the treatment of Barrett's oesophagus (BO), dysplasia, superficial adenocarcinoma (OAC) associated with BO. PATIENTS AND METHODS: Between June 2008 and April 2011, 34 patients underwent treatment with RFA (HALO system(®)), in a tertiary centre. For the study, patients were divided into two groups. Group 1 (16 patients of average 60 years old; 14 men, two women) received EMR and RFA. Group 2 (18 patients averaging 59 years age; 14 men, four women) received RFA without EMR in the year preceding the RFA. RESULTS: In group 1, high grade dysplasia (HGD) was eradicated in 12 cases (92%), low grade dysplasia (LGD) in three cases (100%). Complete response occurred in nine cases (56%), partial response in 100% of cases. Mean follow-up was 15 months. In group 2, HGD was eradicated in one patient (100%), LGD in three patients (64%). A complete response was achieved in eight patients, partial response in four cases (77%). Mean follow-up was 10 months. The complication rate for groups 1 and 2 was of 18% and 10% respectively. No complication prevented completion of treatment or continued monitoring. Recurrence was evaluated to 5% in both groups. CONCLUSION: RFA associated with EMR is feasible, offering probably better results and a very important advantage: a more complete histology before follow-up. Our results show effective treatment of BO and associated dysplasia with a low rate of complication. Nevertheless, when new techniques of BO ablation are used, the need to obtain histology before treatment should not be forgotten.

Results of a phase I-II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis.

BACKGROUND: Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma). METHODS: Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70 µm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection). RESULTS: No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20 µm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20 µm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%. CONCLUSION: This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.

Is neoadjuvant chemotherapy prior to radio-chemotherapy beneficial in T4 anal carcinoma?

BACKGROUND: This study retrospectively describes the outcome of a series of 38 patients (pts) with T4 anal carcinoma exclusively treated by radio and chemotherapy. PATIENTS AND METHODS: From 1992 to 2007, 38 pts with UST4-N0-2-M0 anal carcinoma were treated with exclusive radiotherapy and chemotherapy. All patients received external beam radiotherapy (EBRT) (median dose 45 Gy) with a concomitant chemotherapy (5-fluorouracil-cisplatin). Eleven patients received neo-adjuvant chemotherapy (5-fluorouracil-cisplatin). After 2-8 weeks, a 15-20 Gy boost was delivered either with EBRT (20 pts) or interstitial (192)Ir brachytherapy (18 pts). Mean follow-up was 66 months. RESULTS: After chemoradiation therapy (CRT), 13 pts (34%) had a complete response, 23 pts (60%) a response >50% (2 pts were not evaluated). The 5-year-disease-free survival was 79.2 ± 6.5%, and the 5-year overall survival was 83.9 ± 6%. Eight patients developed tumor progression (mean delay 8.8 months), six of them requiring a salvage surgery with definitive colostomy for local relapse. Late severe complication requiring colostomy was observed in 2 pts. The 5-year-colostomy-free survival was 78 ± 6.9%. Patients who received primary chemotherapy had a statistically significant better 5-year colostomy-free survival (100% vs. 38 ± 16.4%, P = 0.0006). CONCLUSION: T4 anal carcinoma can be treated with a curative intent using a sphincter-sparing approach of CRT, and neo-adjuvant chemotherapy should be considered prior to radiotherapy.

[Frontiers in interventional endoscopy]. / Frontières en endoscopie interventionnelle.

Digestive endoscopy, including endoscopic ultrasound, plays actually an important role in oncology concerning early diagnosis, tumor staging, and therapeutic procedures. Indeed, improvement of endoscope and dedicated accessories allow to increase applications of therapeutic endoscopy in oncologic indications : curative resection of early carcinoma ant submucosa tumor ; palliative treatment of tumoral bilio-digestive obstruction. Possibilities to resect sessile or flat polyps allow to treat curatively well-differentiated carcinoma without infiltration of the muscularis mucosae, the risk of lymph nodes invasion being null in this cases. In case of invasion of muscularis mucosae, this risk is inferior to 1% for colorectal cancer when submucosal invasion do not exceed 1000 microm but this risk is between 6 and 22% in case of oeso-gastric carcinoma invading the third part of the submucosa. Mortality of endoscopic resection was null in almost published series. Morbidity was 15-20% for colorectal resection with 5-6% of severe complications and up to 23% after oesophageal tumor ablation. Moreover, improvement of echoendoscope dedicated to therapeutic procedures allow from now to achieve non-anatomic pancreatic or biliary drainage through the gastric wall when the retrograde route is not suitable (whipple resection, duodenal stricture) or when drainage of the left hepatic lobe is difficult via the retrograde approach. The aim of this technique is to realize an anastomosis between the left hepatic duct and the stomach. Permanence of this fistula is ensured by insertion of one or two stent. Efficacy and safety of this procedure were recently retrospectively evaluated with a technical success in 91% of cases. Therapeutic endoscopy made many progress during the last years and development of new generation of endoscope and accessories would allow a real endoluminal surgical approach for superficial tumor, bilio-digestive anastomosis or gastro-enteroanastomosis by example.

Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) access to the biliary tract is sometimes impossible and percutaneous access has the disadvantages of increased morbidity and patient discomfort. We present our first results with an alternative technique: endoscopic ultrasonography (EUS)-guided transgastric biliary drainage. PATIENTS AND METHODS: 11 patients (7 men, mean age 64 years) were referred for failed ERCP and biliary obstruction (malignancy n = 8, benign conditions n = 3). The retrograde approach via the papilla had been impossible due to surgical anatomy, duodenal stenosis, and hilar stricture with occlusion of the left side. EUS-guided drainage was done with endoscopic and fluoroscopic monitoring. After puncture of the left biliary duct a guide wire was inserted into it followed by tract dilation using a cystostome. A plastic or a metallic stent was placed through this gastrobiliary fistula for bile drainage. RESULTS: EUS-guided left hepaticogastrostomy was successfully performed in 10/11 cases, with one failure of guide wire insertion after puncture. Plastic and covered metal stents were inserted in seven and three patients, respectively. Complications in the plastic stent group included one early occlusion requiring stent replacement, and one transient ileus. In the metallic stent group there was one bilioma and one cholangitis, due to stent shortening. Clinically, the stent was efficacious in all 10 cases; during a mean follow-up of 213 days (range 3-610), two patients presented with stent occlusion and one with stent migration, with successful endoscopic treatment in all. CONCLUSIONS: EUS-guided hepaticogastrostomy is an efficient technique and could be a future alternative to percutaneous biliary drainage or palliative surgical drainage.

Circumferential endoscopic resection of Barrett's esophagus with high-grade dysplasia or early adenocarcinoma.

BACKGROUND: Barrett's esophagus-related high-grade dysplasia or mucosal cancer can be treated by endoscopic mucosal resection (EMR), but the adjacent metaplastic epithelium remains at risk for developing further lesions. Our objective was to evaluate the results of the circumferential EMR in removing not only the neoplastic lesion but also the remaining Barrett's epithelium. METHODS: Forty-one consecutive patients (mean age: 66 years) with Barrett's esophagus were submitted to 63 EMR sessions in one single-referral endoscopic unit. All patients had high-grade dysplasia, and cancer was detected in 23 of these cases, most of them classified as T1N0 (20 patients) by endosonography. Mucosectomy after saline submucosal injection was performed for the neoplastic lesions and, if necessary, the residual Barrett's epithelium was removed by the same technique one month later. RESULTS: A retrospective evaluation showed that, during a mean follow-up of 31.6 months, Barrett's epithelium was completely replaced by squamous epithelium in 31 (75.6%) cases. There were 10 complications, all of which were managed endoscopically: 8 cases of bleeding and two perforations occurred in 9 (14.3%) patients. One patient developed an esophageal stricture. Barrett's epithelium recurred in 10 (24.4%) patients and recurrent or metachronous early cancer was detected in 5 (12.2%), all but one of which were treated again by EMR; the fifth patient was referred to surgery. Argon plasma coagulation was used in 6 cases to treat Barrett's epithelium, and two patients received concomitant chemoradiotherapy as adjuvant therapy. CONCLUSIONS: Circumferential EMR provides an effective endoscopic approach to the management of Barrett's esophagus-related high-grade dysplasia and mucosal cancer. Additional studies are necessary to evaluate the long-term results.

Normal values and day-to-day variability of 24-h ambulatory oesophageal impedance-pH monitoring in a Belgian-French cohort of healthy subjects.

BACKGROUND: Impedance-pH monitoring is the most sensitive method for detection and characterization of gastro-oesophageal reflux episodes. Normal values from European subjects are lacking. AIM: To build a database of gastro-oesophageal reflux patterns from French and Belgian healthy subjects. METHODS: Seventy-two healthy subjects (35 men, mean age 35 years, 18-72) underwent 24-h ambulatory impedance-pH studies. Gastro-oesophageal reflux episodes were detected using impedance and characterized by pH as acid, weakly acidic, or weakly alkaline. Analysis was performed visually and effects of age, gender and intra-individual reproducibility were evaluated. RESULTS: The total number of gastro-oesophageal reflux episodes was 44 (25,58,75) of which 59% were acid, 28% were weakly acidic and 10% weakly alkaline. Half of gastro-oesophageal reflux episodes were mixed (liquid/gas) and 22% reached 15 cm above the lower oesophageal sphincter. The bolus clearance time was 11 s while acid was chemically cleared in 34 s. Male gender was associated with increased number and proximal extent of total and acid gastro-oesophageal reflux. Repeated studies in 27 subjects showed good reproducibility for number, acidity and air-liquid composition of reflux (Kendall's W-values = 0.72-0.85). CONCLUSIONS: This study demonstrates good reproducibility of 24-h ambulatory impedance-pH studies and provides values of reflux patterns in healthy subjects for comparisons with European gastro-oesophageal reflux disease patients.