Performance characteristics and optimal cut-off value of triple adenylate nucleotides test versus adenosine triphosphate test as point-of-care testing for predicting inadequacy of duodenoscope reprocessing.

BACKGROUND: Adenosine triphosphate (ATP) test based on one nucleotide has been applied as point-of-care testing (POCT) for bacterial contamination in the medical and food industries. Hypothetically, testing three adenylate nucleotides (A3) may provide better detection of duodenoscope bacterial contamination than ATP test. AIM: To evaluate performance characteristics and optimal cut-off value of A3 and ATP tests in predicting bacterial contamination of duodenoscopes. METHODS: Four hundred duodenoscope samples obtained after 100 endoscopic retrograde cholangiopancreatography procedures were randomized into group A (A3 test) or B (ATP test). Samples were collected from the elevator at the four-step cleaning process of duodenoscope. We defined the new cut-off value of the test for reaching 100% negative predictive value (NPV) from our receiver operating characteristic (ROC). FINDINGS: Using the cultures from the four-step cleaning process as the reference, the areas under ROC (AUROC) were 0.83 and 0.84 for group A (N = 200) and group B (N = 200), respectively. Using the cultures from post-high-level disinfection (HLD) as the reference, the AUROC were 0.35 and 0.74 for group A (N = 50) and group B (N = 50), respectively. We investigated ATP as a POCT after HLD with a new cut-off value of 40 RLU. However, this threshold did not allow detection of low numbers of bacteria. CONCLUSION: A3 and ATP tests provide good performances in predicting bacterial contamination of duodenoscopes for the four-step cleaning process. The ATP <40 RLU is helpful as a POCT after HLD; however, the limitation of this cut-off value is its inability to detect low numbers of bacteria.

Diagnosis of recurrent rectal cancer deep into the vaginal wall by transvaginal endoscopic ultrasound-guided fine needle aspiration.

Local recurrent rectal cancer may present with extraluminal lesions. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is good for diagnosis of such an extraluminal lesion. A 51-year-old Asian female was diagnosed with uT3N0M0 rectal adenocarcinoma 31 months ago. She had undergone chemotherapy, radiotherapy and abdominoperineal resection (APR). Eight months ago, colonoscopy and computed tomography (CT) were unremarkable. Carcinoembryonic antigen was 1.1 ng/ml. Pelvic examination revealed a 3 x 2 cm firm soft-tissue mass palpable through the left vaginal wall. EUS revealed a mass in the left lateral vaginal wall measuring up to 21 x 27 mm in cross section without invasion of adjacent pelvic structures. Transvaginal EUS-FNA was performed with a 22-gauge needle. Final cytology confirmed recurrent rectal adenocarcinoma. Subsequent surgery also confirmed a 2.3 cm grade II adenocarcinoma. The tumor focally extended to the inked margin. The uterus and ovary specimen were negative for disease. We herein report a successful role of transvaginal EUS-FNA for early detection of recurrent rectal cancer at the vaginal wall after abdominoperineal resection (APR).

EUS and clinical characteristics of cystic pancreatic neuroendocrine tumors.

Pancreatic neuroendocrine tumors (PNETs) may rarely appear as cystic or mixed solid-cystic masses. The endoscopic ultrasound (EUS) morphology and cyst fluid characteristics of these tumors are not well clarified. We retrospectively identified nine adult patients with nine single cystic pancreatic neuroendocrine tumors (CNETs). These nine included 0.67 % of the 1344 patients with pancreatic cystic lesions and 9.5 % of the 95 confirmed PNETs evaluated over the 12-year study period. At presentation, four patients were asymptomatic and five had known acute pancreatitis (n = 2), MEN-1 syndrome with hypoglycemia (n = 1), and abdominal pain (n = 2). Median maximal tumor diameter was 26 mm (range 20 - 64 mm). EUS morphology was mixed solid and cystic (n = 4) or cystic alone (n = 5). Cytology from EUS-fine-needle aspiration (FNA) (median 2 passes; range 1 - 6) demonstrated a PNET, and immunocytochemistry was confirmatory in all patients. Cyst fluid carcinoembryonic antigen (CEA) (n = 4) and amylase (n = 5) ranged from 0.1 to 1.8 ng/ml (normal 0 - 2.5 ng/ml) and 72 to 1838 U/L (normal 25 - 161 U/L), respectively. Six patients underwent surgery, and the preoperative diagnosis was confirmed in all.

Risk of bacteremia in bleeding and nonbleeding gastric varices after endoscopic injection of cyanoacrylate.

BACKGROUND AND STUDY AIM: Bacteremia is common in cirrhosis with gastrointestinal bleeding, including variceal bleeding. Elective esophageal sclerotherapy and banding have been reported to cause bacteremia. The risk associated with therapeutic endoscopy in patients with gastric varices has not yet been reported. This study was conducted to compare the risk of bacteremia between patients with active gastric variceal bleeding and those with gastric varices that were not actively bleeding who underwent N-butyl-2-cyanoacrylate injection. PATIENTS AND METHODS: Patients were categorized into three groups: group I, patients with bleeding gastric varices who underwent cyanoacrylate injection for hemostasis (n = 20); group II, patients who underwent elective cyanoacrylate injection for further obliteration of gastric varices (n = 18); and group III, patients with cirrhosis who underwent endoscopic surveillance for varices, and patients with gastric varices who presented for a follow-up endoscopy without a requirement for treatment (n = 17). Blood culture was obtained before and 5 minutes and 3 hours after endoscopy. Needle tips were also sent for culture. RESULTS: Before procedures, blood cultures were positive in 4 patients (20 %) from group I. The number of positive blood cultures in group I at 5 minutes and 3 hours after the procedure were 3 (15 %) and 2 (10 %) respectively. The identified organisms were: Klebsiella pneumoniae (2), Escherichia coli (1), Vibrio cholerae non-O1 (1). No patient from group II had a positive culture at any point of blood drawn. Only one in group III had a positive culture, for Streptococcus mitis at 5 minutes. No clinical evidence of infections occurred in any patient. Needle-tip cultures grew mainly organisms from the oral and gastrointestinal tracts. CONCLUSIONS: Elective cyanoacrylate injection for nonbleeding gastric varices is not associated with significant bacteremia or infection. For this reason, prophylactic antibiotics may not be needed in this patient group. By contrast, prophylactic antibiotics are strongly recommended for patients with bleeding gastric varices undergoing cyanoacrylate injection.