Endoscopic Ultrasound-Guided Tissue Acquisition Versus Fine Needle Aspiration for Diagnosis of Pancreatic Ductal Adenocarcinoma.

OBJECTIVES: Compare the 22G needle versus EchoTip ProCore® 20 (Cook Medical, Bloomington, IN, USA) on their handling, specimen suitability, amount of tissue obtained, diagnostic performance, the possibility of immunohistochemistry, and rate of adverse events. MATERIALS AND METHODS: This is a retrospective, comparative study of consecutively examined patients with pancreatic masses who underwent endosonography-guided fine needle aspiration (FNA) via the 22G needle, and endosonography-guided tissue acquisition (TA) via ProCore 20 (PC20). The operator evaluated needle insertion and subjectively classified the specimen. The pathologist measured the samples, classified the amount of tissue, and determined the influence of bleeding on the interpretation. RESULTS: A total of 129 patients participated in the study, out of whom 52 underwent endosonography-guided FNA with 22G and 77 underwent endosonography-guided TA with a PC20 needle. Malignant lesions were found in 106, and 23 had benign lesions. The duodenal route was used in 62% of patients. The 22G needle was easier to introduce (p=0.0495). However, PC20 obtained a larger amount (p<0.01) with fewer punctures (p<0.001). The PC20 also yielded a larger average microcore diameter (p=0.0032). Microhistology was adequate for 22G and PC20 in 22 (42.2%) and 50 (78.1%) specimens, respectively (p<0.001). Bleeding was not significantly different (p>0.999). Immunohistochemistry was possible in 36 (69.2%) and 40 (51.9%) specimens obtained by 22G and PC20, respectively (p=0.075). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 22G were 93.5%, 100%, 100%, 66.7%, and 94.2%, respectively; and for PC20, it was 95%, 100%, 100%, 85%, and 96.1%, respectively. Mild bleeding was the most common early adverse event, occurring in 2/52 (3.8%) 22G and 4/77 (5.2%) PC20 cases (p>0.05). CONCLUSIONS: The PC20 required fewer punctures and reduced the need for immunohistochemistry as it yielded better and larger microcores. Its ease of insertion into the target lesion makes it a good option to obtain satisfactory microcore specimens in difficult positions, such as the transduodenal route.

Primary Pancreatic Lymphoma: Endosonography-Guided Tissue Acquisition Diagnosis.

Primary pancreatic lymphoma is a rare type of cancer, that accounts for 0.1-0.5% of lymphomas and about 0.2% of all primary pancreatic tumors. Diffuse Large B-cell Lymphoma is the most common subtype. The diagnosis is possible if the lymphoma is located in the pancreas, but the differential diagnosis with pancreatic ductal adenocarcinoma is difficult. The diagnostic accuracy of endosonography-guided fine needle aspiration is inadequate, and thus it is common to diagnose these masses only after surgical resection. The endosonography-guided tissue acquisition allows greater accuracy in the pancreatic masses, as it determines optimal access to histological analysis using tissue in paraffin blocks for complementary immunohistochemical, and molecular tests. Thus, this elaborate diagnostic environment allows the adoption of appropriate treatment strategies for patients with this condition. The authors describe four cases of primary pancreatic lymphoma indicated for surgical resection due to suspected pancreatic cancer, with the diagnosis of Diffuse Large B-cell Lymphoma obtained by endosonography-guided tissue acquisition, changing the therapeutic strategy through the adoption of adequate chemotherapy treatment with good progress.

First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis.

Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility. The operative time was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up. Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.

Molecular Basis of Hyperammonemic Encephalopathy in Fibrolamellar Hepatocellular Carcinoma.

Hyperammonemic encephalopathy is a potentially fatal condition associated with fibrolamellar hepatocellular carcinoma. The mechanism involved in hyperammonemia in patients with fibrolamellar carcinoma was unclear until a possible physiopathological pathway was recently proposed. An ornithine transcarboxylase dysfunction was suggested as a result of increased ornithine decarboxylase activity induced by c-Myc overexpression. This c-Myc overexpression resulted from Aurora kinase A overexpression derived from the activity of a chimeric kinase that is the final transcript of a deletion in chromosome 19, common to all fibrolamellar carcinomas. We performed the analysis of the expression of all enzymes involved and tested for the mutation in chromosome 19 in fresh frozen samples of fibrolamellar hepatocellular carcinoma, non-tumor liver, and hepatic adenomatosis. The specific DNAJB-PRKACA fusion protein that results from the recurrent mutation on chromosome 19 common to all fibrolamellar carcinoma was detected only in the fibrolamellar carcinoma sample. Fibrolamellar carcinoma and adenomyomatosis samples presented increased expression of Aurora kinase A, c-MYC, and ornithine decarboxylase when compared to normal liver, while ornithine transcarbamylase was decreased. The proposed physiopathological pathway is correct and that overexpression of c-Myc may also be responsible for hyperammonemia in patients with other types of rapidly growing hepatomas. This gives further evidence to apply new and adequate treatment to this severe complication.

Evaluation of cutaneous sensibility on infraorbital nerve area.

Normal facial sensibility on the area of the infraorbital nerve was determined in 24 healthy subjects. The measurement of two points discrimination distance and the evaluation of cutaneous pressure threshold were assessed on both sides on the zygomatic, paranasal, and superior labial skin. Cutaneous sensibility varied from region to region but was consistent from one normal individual to another. Cutaneous sensibility of the superior labial skin was more accurate than zygomatic and paranasal skin in all tests. Sex and dominant sides did not have significant influence on the results. The measurement of two point discrimination distance and the evaluation of cutaneous pressure threshold provided reliable and reproducible data that can be used as a standard to determine facial cutaneous sensibility.