UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS).

BACKGROUND AND AIMS: International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS: Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS: 39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS: An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.

Assessing food and nutrition literacy in children and adolescents: a systematic review of existing tools.

OBJECTIVE: Food literacy (FL) and nutrition literacy (NL) are concepts that can help individuals to navigate the current food environment. Building these skills and knowledge at a young age is important for skill retention, confidence in food practices and supporting lifelong healthy eating habits. The objectives of this systematic review were to: (i) identify existing tools that measure FL and NL among children and/or adolescents and (ii) describe the psychometric properties. DESIGN: A 4-phase protocol was used to systematically retrieve articles. The search was performed in May 2021. Study characteristics and psychometric properties were extracted, and a narrative synthesis was used to summarise findings. Risk of bias was assessed using the COSMIN checklist. SETTING: Six databases were searched to identify current tools. PARTICIPANTS: Children (2-12 years) and adolescents (13-18 years) participated in this study. RESULTS: Twelve tools were identified. Three tools measured FL, 1 tool measured NL, 4 tools measured both FL and NL, and 4 tools measured subareas of NL-more specifically, critical NL, food label and menu board literacy. Most tools were self-reported, developed based on a theoretical framework and assessed some components of validity and/or reliability for a specific age and ethnic group. The majority of tools targeted older children and adolescents (9-18 years of age), and one tool targeted preschoolers (3-6 years of age). CONCLUSIONS: Most widely used definitions of FL and NL do not acknowledge life-stage specific criterion. Continued efforts are needed to develop a comprehensive definition and framework of FL and NL appropriate for children, which will help inform future assessment tools.

Association between diet quality and food waste in Canadian families: a cross-sectional study.

BACKGROUND: Higher diet quality has been associated with greater amounts of food waste among adults in the United States. This study aims to build on previous work by examining the association between diet quality and food waste, as assessed using detailed waste audits, among a sample of Canadian families. METHODS: This cross-sectional study used data from 85 Canadian families with young children. Parent and children diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015), calculated from 3-day food records. Household food waste was measured using detailed waste audits conducted over multiple weeks and these data were used to calculate daily per capita food waste. Linear regression was used to explore the association between parent and child HEI-2015 scores and daily per capita total avoidable and unavoidable food waste, as well as daily per capita avoidable and unavoidable food waste in the following categories: 1) fruits and vegetables, 2) milk, cheese and eggs, 3) meat and fish, 4) breads and cereals, 5) fats and sugars. RESULTS: Parent HEI-2015 scores ranged from 37 to 92 (out of 100) and 81% of parents' diets scored in the "Needs Improvement (51-80)" category. Parent and child diet quality scores were significantly correlated (r = 0.61; P < 0.0001) and 82% of children's diets scored in the "Needs Improvement" category. On average, households produced 107 g of avoidable food waste and 52 g of unavoidable food waste per person per day. Fruits and vegetables were the highest contributor for both avoidable and unavoidable food waste. Both parent and child HEI-2015 scores were not significantly associated with total daily per capita avoidable or unavoidable food waste. However, parent HEI-2015 scores were positively associated with daily per capita avoidable fruit and vegetable waste (Unstandardized ß = 1.05; 95%CI: 0.11, 1.99; P = 0.03) and daily per capita unavoidable fruit and vegetable waste (Unstandardized ß = 0.60; 95%CI: 0.03, 1.17; P = 0.04), after adjusting for household income. CONCLUSION: This is the first study to explore the association between diet quality and food waste using detailed waste audits. Future research should explore effective strategies towards improving diet quality while simultaneously reducing food waste, especially of fruits and vegetables.

Linear endobronchial ultrasonography: a novelty turned necessity for mediastinal nodal assessment.

Linear endobronchial ultrasound was first described in 2003. Since then the technique has spread rapidly and has now become an established practice in many centres as the first-line mediastinal investigation for the diagnosis and staging of lung cancer. In combination with endoscopic ultrasound, the majority of the mediastinum can be assessed and this approach has been shown to have equivalent accuracy to surgical staging. This strategy is also cost-effective. New tissue processing techniques using liquid-based thin-layer cytology and cell blocks have increased diagnostic yield using immunohistochemical staining and molecular diagnostics. Several meta-analyses of case series and, more recently, randomised controlled trials have provided high-level evidence of efficacy leading to incorporation into national lung cancer staging guidelines. In addition, linear endobronchial ultrasound is increasingly used in the investigation of mediastinal lymphadenopathy for suspected sarcoidosis, tuberculosis and lymphoma. While undoubtedly endobronchial/endoscopic ultrasound has reduced the need for surgical staging in lung cancer, the latter still has an important role to play in certain scenarios. The challenge now facing clinicians is to learn to apply the appropriate test or sequence of tests in each patient while ensuring that operators are appropriately trained in order to ensure optimal outcomes.

Location of lymph node involvement in patients with esophageal adenocarcinoma predicts survival.

BACKGROUND: The location of positive lymph nodes has been abandoned in the seventh classification of the TNM staging system for esophageal adenocarcinoma. The present study evaluates whether distribution of involved nodes relative to the diaphragm in addition to TNM 7 further refines prediction. METHODS: Pathology reports of patients who underwent esophagectomy between 2000 and 2008 for adenocarcinoma of the esophagus were reviewed and staging was performed according to the seventh UICC-AJCC staging system. In addition, lymph node involvement of nodal stations above and below the diaphragm was investigated by endoscopic ultrasonography (EUS) in a separate cohort of patients who were scheduled for esophagectomy between 2008 and 2009 at two institutions. Survival was calculated by the Kaplan-Meier method, and multivariate analysis was performed with a Cox regression model. RESULTS: Some 327 patients who had undergone esophagectomy for cancer were included. Multivariate analysis revealed that patients with from three to six involved lymph nodes in the resection specimen on both sides of the diaphragm had a twofold higher chance of dying compared to patients with the same number of involved lymph nodes on one side of the diaphragm. EUS assessment of lymph node metastases relative to the diaphragm in 102 patients showed that nodal involvement on both sides of the diaphragm was associated with worse survival than when nodes on one side or no nodes are involved [HR (95 % CI) 2.38 (1.15-4.90)]. CONCLUSIONS: A combined staging system that incorporates distribution of lymph nodes relative to the diaphragm refines prognostication after esophagectomy as assessed in the resected specimen and pretreatment as assessed by EUS. This improved staging has the potential to have a great impact on clinical decision making as to whether to embark upon potentially curative or palliative treatments.

Direct histological processing of EUS biopsies enables rapid molecular biomarker analysis for interventional pancreatic cancer trials.

OBJECTIVE: Current practice to diagnose pancreatic cancer is accomplished by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) using a cytological approach. This method is time consuming and often fails to provide suitable specimens for modern molecular analyses. Here, we compare the cytological approach with direct formalin fixation of pancreatic EUS-FNA micro-cores and evaluate the potential to perform molecular biomarker analysis on these specimen. METHODS: 130 specimens obtained by EUS-FNA with a 22G needle were processed by the standard cytological approach and compared to a separate cohort of 130 specimens that were immediately formalin fixed to preserve micro-cores of tissue prior to routine histological processing. RESULTS: We found that direct formalin fixation significantly shortened the time required for diagnosis from 3.6 days to 2.9 days (p<0.05) by reducing the average time (140 vs 33 min/case) and number of slides (9.65 vs 4.67 slides/case) for histopathological processing. Specificity and sensitivity yielded comparable results between the two approaches (82.3% vs 77% and 90.9% vs 100%). Importantly, EUS-FNA histology preserved the tumour tissue architecture with neoplastic glands embedded in stroma in 67.89% of diagnostic cases compared to 27.55% with the standard cytological approach (p < 0.001). Furthermore, micro-core samples were suitable for molecular studies including the immunohistochemical detection of intranuclear Hes1 in malignant cells, and the laser-capture microdissection-mediated measurement of Gli-1 mRNA in tumour stromal myofibroblasts. CONCLUSIONS: Direct formalin fixation of pancreatic EUS-FNA micro-cores demonstrates superiority regarding diagnostic delay, costs, and specimen suitability for molecular studies. We advocate this approach for future investigational trials in pancreatic cancer patients.

Food Skills: Associations With Diet Quality and Food Waste Among Canadian Parents.

OBJECTIVE: To examine the association between self-reported food skills and diet quality along with measured food waste among a sample of Canadian parents. DESIGN: Cross-sectional data from surveys to assess food skills, 3-day food records to assess the Healthy Eating Index (HEI)-2015, and food waste measured by household waste audits. SETTING: Guelph-Wellington, Ontario. PARTICIPANTS: Parents (n = 130) with children aged 2-8 years. MAIN OUTCOME MEASURES: HEI-2015 scores, daily per capita avoidable and unavoidable food waste (grams). ANALYSIS: Linear regression using generalized estimating equations to determine unstandardized ß estimates of associations between food skills and dependent variables. Models were adjusted for multiple testing, gender, and level of education. RESULTS: Food safety knowledge for cooking hot foods (ß = 4.3, P = 0.05), planning (ß = 4.5, P = 0.001), and conceptualizing food (ß = 4.0, P = 0.03) were positively associated with HEI-2015 scores. Knowledge related to best before dates (ß = 25.3, P = 0.05; ß = 12.1, P = 0.04), conceptualizing food (ß = 34.1, P = 0.01; ß = 13.8, P = 0.02), and mechanical techniques (ß = 39.2, P = 0.01; ß = 20.5, P = 0.004) were associated with more avoidable and unavoidable food waste, respectively. CONCLUSIONS AND IMPLICATIONS: Addressing higher-level food skills with a focus on efficient food preparation practices that make use of all edible portions of foods could play an important role in minimizing food waste and improving diet quality. Additional research in other countries and in a larger, more socioeconomically diverse sample is needed to confirm these findings.

Endoscopic ultrasound: a review of current diagnostic and therapeutic applications.

Endoscopic ultrasound (EUS) has become important in a variety of clinical settings. Echoendoscopes may be categorised into radial and linear configurations. Radial devices are used for diagnostic imaging, whereas linear echoendoscopes also facilitate image guided tissue sampling and intervention. EUS is an established primary diagnostic tool for a number of conditions including choledocholithiasis and biliary microlithiasis. It is therefore well suited to the investigation of the aetiology of pancreatitis where simpler measures fail to identify the aetiology. It can also be used to identify chronic non-calcific pancreatitis. EUS is important in the secondary evaluation of abnormalities detected by other imaging modalities-for example, cystic pancreatic lesions. The high resolution of EUS allows more detailed image based analysis than other imaging modalities. The ability to sample cyst fluid significantly increases the accuracy of lesion characterisation. Most importantly, EUS has become indispensable in the staging of a variety of upper gastrointestinal tract tumours. If resection is being considered, the high resolution images obtained via EUS are invaluable for local tumour staging. EUS guided tissue sampling permits accurate nodal staging without relying on lymph node size as proxy for malignant infiltration. In patients with contraindications to magnetic resonance imaging, EUS is an alternative for the staging of rectal carcinoma. It is used in the staging of lung cancer, often in combination with endobronchial ultrasound. Finally, EUS is used therapeutically in image guided drainage (such as gastrocystostomy in pancreatic pseudocyst) and coeliac plexus neurolysis in patients with abdominal pain caused by pancreatic cancer or pancreatitis.

Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial.

CONTEXT: Mediastinal nodal staging is recommended for patients with resectable non-small cell lung cancer (NSCLC). Surgical staging has limitations, which results in the performance of unnecessary thoracotomies. Current guidelines acknowledge minimally invasive endosonography followed by surgical staging (if no nodal metastases are found by endosonography) as an alternative to immediate surgical staging. OBJECTIVE: To compare the 2 recommended lung cancer staging strategies. DESIGN, SETTING, AND PATIENTS: Randomized controlled multicenter trial (Ghent, Leiden, Leuven, Papworth) conducted between February 2007 and April 2009 in 241 patients with resectable (suspected) NSCLC in whom mediastinal staging was indicated based on computed or positron emission tomography. INTERVENTION: Either surgical staging or endosonography (combined transesophageal and endobronchial ultrasound [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread. MAIN OUTCOME MEASURES: The primary outcome was sensitivity for mediastinal nodal (N2/N3) metastases. The reference standard was surgical pathological staging. Secondary outcomes were rates of unnecessary thoracotomy and complications. RESULTS: Two hundred forty-one patients were randomized, 118 to surgical staging and 123 to endosonography, of whom 65 also underwent surgical staging. Nodal metastases were found in 41 patients (35%; 95% confidence interval [CI], 27%-44%) by surgical staging vs 56 patients (46%; 95% CI, 37%-54%) by endosonography (P = .11) and in 62 patients (50%; 95% CI, 42%-59%) by endosonography followed by surgical staging (P = .02). This corresponded to sensitivities of 79% (41/52; 95% CI, 66%-88%) vs 85% (56/66; 95% CI, 74%-92%) (P = .47) and 94% (62/66; 95% CI, 85%-98%) (P = .02). Thoracotomy was unnecessary in 21 patients (18%; 95% CI, 12%-26%) in the mediastinoscopy group vs 9 (7%; 95% CI, 4%-13%) in the endosonography group (P = .02). The complication rate was similar in both groups. CONCLUSIONS: Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00432640.

The Impact of COVID-19 on Health Behavior, Stress, Financial and Food Security among Middle to High Income Canadian Families with Young Children.

The COVID-19 pandemic has disrupted many aspects of daily life. The purpose of this study was to identify how health behaviors, level of stress, financial and food security have been impacted by the pandemic among Canadian families with young children. Parents (mothers, n = 235 and fathers, n = 126) from 254 families participating in an ongoing study completed an online survey that included close and open-ended questions. Descriptive statistics were used to summarize the quantitative data and qualitative responses were analyzed using thematic analysis. More than half of our sample reported that their eating and meal routines have changed since COVID-19; most commonly reported changes were eating more snack foods and spending more time cooking. Screen time increased among 74% of mothers, 61% of fathers, and 87% of children and physical activity decreased among 59% of mothers, 52% of fathers, and 52% of children. Key factors influencing family stress include balancing work with childcare/homeschooling and financial instability. While some unhealthful behaviors appeared to have been exacerbated, other more healthful behaviors also emerged since COVID-19. Research is needed to determine the longer-term impact of the pandemic on behaviors and to identify effective strategies to support families in the post-COVID-19 context.

Test performance and predictors of accuracy of endoscopic ultrasound-guided fine-needle aspiration for diagnosing biliary strictures or masses.

Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as an important method for obtaining a preoperative tissue diagnosis for suspected cholangiocarcinoma. However, doubts remain about test sensitivity. This study assessed the value and limitations of EUS-FNA in clinical practice. Patients and methods Patients undergoing EUS-FNA for biliary strictures/masses at a UK tertiary referral center from 2005 to 2014 were prospectively enrolled. Data on EUS-FNA findings, histology, and endoscopy and patient outcomes were collected to evaluate test performance and identify factors predictive of an inaccurate diagnostic result. Results Ninety-seven patients underwent a total of 112 EUS-FNA procedures. Overall test sensitivity for an initial EUS-FNA for suspected cholangiocarcinoma was 75 % (95 % CI 64 %-84 %), with specificity 100 % (95 % CI 85 %-100 %) and negative predictive value 0.62 (95 % CI 0.47-0.75). Hilar lesions, the presence of a biliary stent, and a diagnosis of PSC were significantly independently associated with an inaccurate result. For the most difficult cases, repeat sampling and use of the Papanicolaou cytopathology grading scale led to an increase in test sensitivity from 17 % to 100 % ( P  = 0.015) with no loss of specificity. Conclusions EUS-FNA was found to be a useful method for obtaining a preoperative tissue diagnosis for patients with suspected cholangiocarcinoma. This study identified markers that can reduce test accuracy and measures that can improve test performance of EUS-FNA.

EBUS-TBNA for the diagnosis of central parenchymal lung lesions not visible at routine bronchoscopy.

BACKGROUND: Obtaining a tissue diagnosis of malignancy is challenging in patients with suspected lung cancer presenting with centrally located intrapulmonary masses. OBJECTIVE: (1) To evaluate the yield of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) for diagnosing centrally located lesions after a non-diagnostic conventional bronchoscopy. (2) To assess the impact of EBUS-TBNA on patient management for this indication. STUDY DESIGN AND PATIENTS: A retrospective analysis of a series of patients with a central parenchymal lung lesion suspected to be lung cancer who had been referred to three university hospitals for EBUS-TBNA to obtain a tissue diagnosis was undertaken. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were subsequently referred for a transthoracic needle aspiration biopsy or a surgical diagnostic procedure. RESULTS: Sixty patients were investigated with EBUS-TBNA. The majority (82%) had a prior (non-diagnostic) flexible bronchoscopy. EBUS-TBNA was performed in an out-patient setting in 97%. With ultrasound, the primary lung lesion was observed in all cases. EBUS-TBNA confirmed lung cancer in 46 (77%). A final reference pathology diagnosis was available in 59 (98%) cases. The sensitivity of EBUS-TBNA for diagnosing lung cancer was 82% (95% confidence intervals (CI) 69-91%) with a negative predictive value of 23% (95%CI 5-53%). Based on the EBUS-TBNA findings, transthoracic needle aspiration biopsy or a surgical diagnostic procedure was cancelled in 47% and 30% of patients, respectively. No serious procedure-related complications were reported. CONCLUSION: EBUS-TBNA is a sensitive tool for the diagnosis of centrally located primary lung cancer not visible at conventional bronchoscopy. Therefore, EBUS-TBNA can impact on patient management in this setting. However, the low negative predictive value indicates that a negative EBUS-TBNA result should be confirmed by other methods. IMPLICATION: EBUS-TBNA can be considered as a diagnostic test in patients with a centrally located lung lesion after a previous non-diagnostic conventional bronchoscopy.

Radiation exposure during laparoscopic cholecystectomy with routine intraoperative cholangiography.

BACKGROUND: For many years, intraoperative cholangiography during cholecystectomy to aid definition of the biliary anatomy and to detect choledocholithiasis has been advocated. Although radiation exposure in fluoroscopic procedures is a concern, few available data exist regarding the radiation exposure incurred during intraoperative cholangiography. This study aimed to determine the average radiation exposure sustained during this procedure. METHODS: Radiation dose data were recorded between 5 September 2007 and 21 July 2008 for 108 consecutive patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography. Dose area product values were used to calculate the entrance skin dose, an indicator of potential skin damage, and the effective dose, an indicator of long-term cancer risk, for each patient. RESULTS: The median age of the 108 patients (67% females) included in the data analysis was 51 years (range, 17-87 years). The mean entrance skin dose during intraoperative cholangiography was 0.0069 +/- 0.0066 Gy, and the mean effective dose was 0.18 +/- 0.17 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the lifetime risk for the development of new cancer due to intraoperative cholangiography was less than 0.001%. CONCLUSION: Radiation doses administered during intraoperative cholangiography are safe and do not represent a contraindication to this procedure.

Valuing the Multiple Impacts of Household Food Waste.

The Commission for Environmental Cooperation (CEC) has estimated that Canadian households waste 85 kg of food per person annually. Food waste has become an increasingly common focus for policy, regulation, interventions, and awareness-raising efforts in Canada. However, there is still a relative dearth of data to inform such decision-making processes or to provide narratives to contextualize behavior change efforts. In this paper, we describe the results of an uncommonly detailed observational study of household food waste. A total of 94 families with young children living in Guelph, Ontario chose to participate in this study. Over the course of multiple weeks, we collected data on their food purchases, food consumption, and waste generation. All three streams of waste (garbage, recycling, and organic waste) were audited and the food type, degree of avoidability, and weight of each individual component of the organic waste stream was recorded. Using this highly granular data set, we found that the average household in our study generated approximately 2.98 kg of avoidable food waste per week. This estimate was then contextualized in terms of economic losses (dollar value), nutritional losses (calories, vitamins, and minerals) and environmental impacts (global warming potential, land, and water usage). In short, weekly avoidable food waste per household was calculated to be equivalent to $18.01, 3,366 calories, and 23.3 kg of CO2. These multiple valuation frameworks, which are based in detailed observations of family food behaviors rather than estimations derived from system-wide data, will enable more informed and urgent conversations about policy, programming, and interventions in order to reduce the volume of wasted food at the consumer level.

A prospective trial of CONfocal endomicroscopy in CYSTic lesions of the pancreas: CONCYST-01.

Background and study aims Pancreatic cystic lesions (PCL) are common. While some harbor malignant potential, accurate preoperative diagnosis remains challenging. Needle-based confocal laser endomicroscopy (nCLE) via a 19G FNA needle enables real-time imaging of the cyst wall. This study evaluated the safety and utility of nCLE in patients with an indeterminate PCL undergoing EUS-FNA. Patients and methods The CONCYST study prospectively recruited patients with indeterminate PCL attending three hepatopancreaticobiliary (HPB) referral centers in the UK, with indeterminate PCL, who required EUS-FNA between July 2014 and October 2016. Following the procedure, all patients were followed up in telephone clinic for at least 12 months. Ethical approval for the study was granted by the National Research Ethics Service (14/LO/0040). Results Sixty-seven patient were recruited, 11 excluded and 56 included in the final analysis: 35 male, 21 female; median age 68 (range 28 - 80). Recognizable confocal images were obtained in 48 of 56 cases. Median nCLE scanning time was 5 minutes and did not exceed 10 minutes in any case. EUS-nCLE findings correlated with final diagnosis (based on imaging, cytology and multidisciplinary team review) in 43/56 (77 %) of cases, compared with 37/56 (66 %) for cytology alone ( P  = 0.12). One patient experienced mild pruritus following the procedure and another developed an infected pseudocyst, which resolved with antibiotics. Conclusions EUS-nCLE under conscious sedation in the day case setting is safe and provides additional information to standard EUS-FNA for diagnosing indeterminate PCL.

Treatment of wild-type gastrointestinal stromal tumor (WT-GIST) with imatinib and sunitinib.

We report a rare case of advanced, metastatic gastrointestinal stromal tumor (GIST) in a young female. Molecular analysis of the tumor revealed wild-type (WT) KIT and platelet derived growth factor receptor alpha (PDGFRA) gene status with no mutations characteristic of adult GIST. Despite this she had clinical benefit and evidence of radiological response to sequential treatment with the tyrosine kinase inhibitors imatinib and sunitinib.

Endoscopic ultrasound-guided drainage of an abdominal fluid collection following Whipple's resection.

Percutaneous aspiration and drainage of post-operative abdominal fluid collections is a well established standard technique. However, some fluid collections are not amenable to percutaneous drainage either due to location or the presence of surrounding visceral structures. Endoscopic Ultrasound (EUS) has been widely used for the drainage of pancreatitis-related abdominal fluid collections. However, there are no reports on the use of this technique in the post-operative setting. We report a case where the EUS-guided technique was used to drain a percutaneously inaccessible post-operative collection which had developed after Whipple's resection.