Search

Background: Acute pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this noninferiority study was to evaluate the effectiveness of pancreatic duct (PD) stenting plus pharmacological prophylaxis vs. pharmacological prophylaxis alone in the prevention of post-ERCP pancreatitis (PEP) in high risk patients.Methods: In this randomized, controlled, double-blind, noninferiority trial, patients at high risk of developing PEP were randomly allocated to pharmacological prophylaxis (rectal indomethacin, sublingual isosorbide dinitrate, and intravenous hydration with Ringer's lactate) plus PD stenting (group A) or pharmacological prophylaxis alone (group B). The rate and severity of PEP, serum amylase levels, and length of hospital stay after ERCP were assessed.Results: During 21 months, a total of 414 patients (mean age 55.5 ± 17.0 years; 60.2 % female) were enrolled (207 in each group). PEP occurred in 59 patients (14.3 %, 95 % confidence interval [CI] 11.1 % - 17.9 %: 26 patients [12.6 %, 95 %CI 8.6 % - 17.6 %] in group A and 33 [15.9 %, 95 %CI 11.4 % - 21.4 %] in group B). There was no significant difference between the two groups in PEP severity (P = 0.59), amylase levels after 2 hours (P = 0.31) or 24 hours (P = 0.08), and length of hospital stay (P = 0.07).Conclusions: The study failed to demonstrate noninferiority or inferiority of pharmacological prophylaxis alone compared with PD stenting plus pharmacological prophylaxis in the prevention of PEP in high risk patients. [ABSTRACT FROM AUTHOR]

Treatment of choledocholithiasis and cholelithiasis in patients with cirrhosis often requires diagnostic and therapeutic endoscopy such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Patients with underlying cirrhosis may have coagulopathy, hepatic encephalopathy, ascites and other comorbidities associated with cirrhosis that can make endoscopic therapy challenging and can be associated with a higher risk of adverse events. Given the unique derangements of physiologic parameters associated with cirrhosis this population requires a truly multifaceted and multidisciplinary understanding between therapeutic endoscopists, hepatologists and anesthesiologists. For therapeutic endoscopists, it is critical to be aware of the specific issues unique to this population of patients to optimize outcomes and avoid adverse events. The epidemiology of gallstone disease, the diagnostic and therapeutic approach to patients with varying degree of hepatic dysfunction, and a review of the available literature in this area are presented. [ABSTRACT FROM PUBLISHER]

Background and Aim: Recent data have suggested that rectal indomethacin can also reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The aim of this study was to determine whether prophylactic rectal indomethacin with PD stenting would reduce the incidence and severity of PEP compared to PD stenting alone in patients undergoing manometry for suspected SOD type 3. Patients and Methods: A retrospective review of consecutive patients who underwent an ERCP with manometry for suspected SOD type 3 was performed. Patients were divided into two groups: (a) those who received a prophylactic PD stent ( n = 285) and (b) those who received a prophylactic PD stent and a single dose of 100-mg indomethacin suppositories after ERCP ( n = 57). The rate of PEP was compared between the two groups. Results: The two patient groups were similar with regard to patient and procedure risk factors for PEP. Post-ERCP pancreatitis developed in 22 % patients. There was no significant difference in the incidence of PEP in the PD stent group compared to the PD stent and indomethacin group (23 vs. 18 %, respectively; p = 0.39). Moderate-to-severe pancreatitis developed in 21 (7 %) patients in the PD stent group compared to 5 (9 %) patients in the PD stent and indomethacin group ( p = 0.78). Among patients with PEP, the median length of hospital stay was not significantly longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4 days, respectively; p = 0.11). Conclusions: In patients with suspected SOD type 3, prophylactic rectally administered indomethacin with PD stenting was not observed to affect the incidence or severity of post-ERCP pancreatitis when compared to PD stenting alone. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of aspirin and anticoagulants on clinical outcomes and cause of in-hospital death in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). Methods: Patients were identified from a tertiary center database that included all patients with UGIB. Clinical outcomes including (1) in-hospital mortality, (2) severe bleeding, (3) rebleeding, (4) in-hospital complications, and (5) length of hospital stay were examined in patients taking (a) aspirin only, (b) anticoagulants only, and (c) no antithrombotics. Results: Of 717 patients with NVUGIB, 56 % (402) were taking at least one antithrombotic agent. Seventy-eight (11 %) patients died in hospital, and 310 (43 %) had severe bleeding (BP < 90 mmHg, HR > 120 b/min, Hb < 7 g/dL on presentation, or transfusion of >3 units). On multivariate analysis, being on aspirin was protective against in-hospital mortality [OR 0.26 (0.13-0.53)], rebleeding [OR 0.31 (0.17-0.59)], and predictive of a shorter hospital stay (coefficient = −4.2 days; 95 % CI −8.7, 0.3). Similarly, being on nonaspirin antiplatelets was protective against in-hospital mortality ( P = 0.03). However, being on anticoagulants was predictive of in-hospital complications [OR 2.0 (1.20-3.35)] and severe bleeding [OR 1.69 (1.02-2.82)]. Compared to those not taking any antithrombotics, patients who bled on aspirin were less likely to die in hospital of uncontrolled gastrointestinal bleeding (3.6 vs 0 %, P ≤ 0.01) and systemic cancer (4.9 vs 0 %, P ≤ 0.002), but equally likely to die of cardiovascular/thromboembolic disease, sepsis, and multiorgan failure. Conclusion: Patients who present with NVUGIB on aspirin had reduced in-hospital mortality and fewer adverse outcomes, while those on anticoagulants had increased in-hospital complications. [ABSTRACT FROM AUTHOR]

Background and study aims: Stones in the cystic duct stump (CDS) or gallbladder remnant after cholecystectomy are difficult to identify. The aim of this study was to evaluate the utility of endoscopic ultrasound (EUS) in the diagnosis of stones in the CDS or gallbladder remnant in patients with postcholecystectomy syndrome. Methods: A prospective study was conducted between January 2011 and December 2012 in consecutive patients with pancreaticobiliary-type pain or acute pancreatitis (n=112) following cholecystectomy. Diagnostic modalities including EUS were used to diagnose the cause of postcholecystectomy syndrome. Results: A total of 11 patients (10 %) were found to have stones in the gallbladder remnant (n=8), CDS (n=2), or both (n=1). In eight patients, EUS was the first imaging procedure to make the diagnosis. Seven patients agreed to undergo repeat surgery, and six of them remained free of symptoms postoperatively after a median follow-up period of 4 months (range 1-13 months). Conclusion: EUS may be an important procedure to consider in the study of patients with symptoms after cholecystectomy, as the diagnosis of residual stones is frequently missed by other imaging modalities. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Acute pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Recent data suggest that indomethacin can reduce the risk of post-ERCP pancreatitis (PEP) in high-risk individuals. However, whether the combination of indomethacin and sublingual nitrates is superior to indomethacin alone is unknown. Therefore, we aimed to evaluate the efficacy of rectally administered indomethacin plus sublingual nitrate compared with indomethacin alone to prevent PEP.METHODS:During a 17-month period, all eligible patients who underwent ERCP were enrolled in this study. We excluded patients who had undergone a prior endoscopic sphincterotomy. In a double-blind controlled randomized trial, patients received a suppository containing 100 mg of indomethacin, plus 5 mg of sublingual nitrate (group A), or a suppository containing 100 mg of indomethacin, plus sublingual placebo (group B), before ERCP. Serum amylase levels and clinically pertinent evaluations were measured in all patients after ERCP.RESULTS:Of the 300 enrolled patients, 150 received indomethacin plus nitrate. Thirty-three patients developed pancreatitis: 10 (6.7%) in group A and 23 (15.3%) in group B (P=0.016, risk ratio=0.39, 95% confidence intervals (CI): 0.18-0.86). More than 80% of the patients were at high risk of developing pancreatitis after ERCP. Absolute risk reduction, relative risk reduction, and number needed to treat for the prevention of PEP were 8.6% (95% CI: 4.7-14.5), 56.2% (95% CI: 50.6-60.8), and 12 (95% CI: 7-22), respectively.CONCLUSIONS:Combination of rectal indomethacin and sublingual nitrate given before ERCP was significantly more likely to reduce the incidence of PEP than indomethacin suppository alone. Multicenter trials to confirm these promising findings are needed. [ABSTRACT FROM AUTHOR]

Objective We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB). Methods The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded. Results Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = −3.4, 95% CI [−6.6, −0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events ( OR 2.3, 95% CI 1.0-5.3), severe bleeding ( OR 2.6, 95% CI 1.2-5.8) and in-hospital complications ( OR 2.9, 95% CI 1.3-6.6). Conclusions Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population. [ABSTRACT FROM AUTHOR]

McKittrick-Wheelock syndrome is a rare disease characterized by a large hypersecretory rectosigmoid villous adenoma resulting in persistent large volume diarrhea, electrolyte abnormalities, and renal dysfunction. We report an unusual presentation of this syndrome in a patient who developed persistent diarrhea along with dermatomyositis and rectal prolapse and was later discovered to have a large rectal villous adenoma along with a smaller sigmoid tubulovillous adenoma. In our literature review, we were able to find one case report of a dermatomyositis occurring in conjunction with a tubulovillous adenoma and few case reports of rectal prolapse in the setting of a secretory villous adenoma. However, there were no reports on both occurring in association with McKittrick-Wheelock syndrome. This report highlights the variable manifestations of colorectal adenomas and the importance of searching for an underlying neoplastic entity in patients with new onset dermatomyositis or rectal prolapse or both. [ABSTRACT FROM AUTHOR]

Background and Aims: Rapid onsite evaluation (ROSE) has been demonstrated to correlate with final cytologic interpretations and improves the diagnostic yield of endoscopic ultrasound (EUS)-fine needle aspiration (FNA); however, its availability is variable across centers. The aim of this prospective study was to evaluate whether remote telecytology can substitute for ROSE. Methods: Consecutive patients who underwent EUS-FNA for diverse indications at a high volume referral center were enrolled and all samples were prospectively evaluated by three methods. ROSE was performed by a cytopathologist in the procedure room; simultaneously dynamic telecytology was done by a different cytopathologist in a remote location at our institution. The third method, final cytologic interpretation in the laboratory, was the gold standard. Telecytology was performed using an Olympus microscope system (BX) which broadcasts live images over the Internet. Accuracy of telecytology and agreement with other methods were the principle outcome measurements. Results: Twenty-five consecutive samples were obtained from participants 40-87 years old (median age 63, 48 % male). There was 88 % agreement between telecytology and final cytology ( p < 0.001) and 92 % agreement between ROSE and final cytology ( p < 0.001). There was consistency between telecytology and ROSE ( p value for McNemar's χ = 1.0). Cohen's kappa for agreement for telecytology and ROSE was 0.80 (SE = 0.11), confirming favorable correlation. Conclusion: Dynamic telecytology compares favorably to ROSE in the assessment of EUS acquired fine needle aspirates. If confirmed by larger trials, this system might obviate the need for onsite interpretation of EUS-FNA specimens. [ABSTRACT FROM AUTHOR]

Colorectal cancer screening, while effective for reducing mortality, remains underutilized particularly among underserved populations such as African Americans. The present study evaluated a spiritually based approach to increasing Health Belief Model–based pre-screening outcomes in a Community Health Advisor–led intervention conducted in African American churches. Sixteen urban churches were randomized to receive either the spiritually based intervention or a nonspiritual comparison of the same structure and core colorectal cancer content. Trained Community Health Advisors led a series of two educational sessions on colorectal cancer early detection. The educational sessions were delivered over a 1-month period. Participants (N = 316) completed a baseline survey at enrollment and a follow-up survey one month after the first session. Both interventions resulted in significant pre/post increases in knowledge, perceived benefits of screening, and decreases in perceived barriers to screening. Among women, the spiritually based intervention resulted in significantly greater increases in perceived benefits of screening relative to the nonspiritual comparison. This finding was marginal in the sample as a whole. In addition, perceived benefits to screening were associated with behavioral intention for screening. It is concluded that in this population, the spiritually based was generally as effective as the nonspiritual (secular) communication. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Prior studies have reported that the presence of prior biliary stent may interfere with EUS visualization of pancreatic tumors. We aimed to compare the influence of the biliary plastic and fully covered self-expanding metal stents (CSEMS) on the accuracy of EUS-FNA cytology in patients with solid pancreatic masses. Patients and Methods: We conducted a retrospective study evaluating 677 patients with solid pancreatic head/uncinate lesions and a previous biliary stent in whom EUS-FNA was performed. The patients were stratified into two groups: (1) those with a plastic stents and (2) those with CSEMS. Performance characteristics of EUS-FNA including the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were compared between the two groups. Results: The frequency of obtaining an adequate cytology by EUS-FNA was similar in both the CSEMS group and the plastic stent group (97 vs. 97.1 % respectively; p = 1.0). The sensitivity, specificity, and accuracy of EUS-FNA was not significantly different between patients with CSEMS and plastic stents (96.8, 100, 100 % and 97.3, 98, 99.8 %, respectively). The negative predictive value for EUS-FNA was lower in the CSEMS group compared to the plastic stent group (66.6 vs. 78.1 % respectively; p = 0.42). There was one false-positive cytology in the plastic stent group compared to none in the CSEMS group. Conclusions: In a retrospective cohort trial, EUS-FNA was found to be highly accurate and safe in diagnosing patients with suspected pancreatic cancer, even in the presence of a plastic or metallic biliary stent. The presence of a stent did not contribute to a higher false-positive cytology rate. [ABSTRACT FROM AUTHOR]

Background: Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia. Methods: 37 patients underwent placement of a SEMS during a 3 year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures. Results: SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain ( n = 6), severe heartburn ( n = 1), and upper gastrointestinal bleeding requiring SEMS revision ( n = 1). Dysphagia scores improved significantly from 3.2 ± 0.4 before stent placement to 1.4 ± 1.0 at 1 month ( P < 0.0001), 1.1 ± 1.2 ( P < 0.0001) at 3 months, and 1.3 ± 1.4 ( P = 0.0018) at 6 months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture ( n = 3), stent malfunction ( n = 5), and stent migration ( n = 3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3 ± 143.6 (range, 13-680) days. Conclusions: Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required. [ABSTRACT FROM AUTHOR]

PURPOSE: Mediastinal lymphadenopathy (ML) is a cause for concern, especially in patients with previous malignancy. We report our experience with the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with immunocytochemical stains in patients being evaluated for ML. METHODS: Retrospective analysis of patients with ML of unknown origin who underwent EUS-FNA. On-site evaluation was performed by experienced cytologist, and special immunocytochemical stains were requested as indicated. RESULTS: A total of 116 patients were included, and a total of 136 mediastinal LN were sampled. Prior malignancy was present in 45%. The most common site of examined lymph node (LN) were subcarinal (76%, 103 LN). The median long and short axis diameters were 28 mm and 13 mm, respectively. FNA was read on-site as malignant, 21 (16%); benign, 100 (76.9%); suspicious, six (4%); atypical, 3 (2%); and inadequate sample, six (4%). Sixty-four LN were deferred for additional studies; 22 for immunocytochemical and 26 for Gimesa (GMS) stain and 21 for flow cytometry. Final FNA read was malignant in 28 (21%), benign in 103 (76%), suspicious in three (2%), and atypical in two (1%). Metastatic malignancies disclosed included Hodgkin's and Non-Hodgkin's lymphoma, melanoma, hepatoma, breast, lung, colon, renal, endometrial, Fallopian tube, and unknown carcinoma. The sensitivity, specificity, and accuracy of the final FNA read to predict malignancy were 100%. CONCLUSION: EUS-guided FNA with additional ancillary studies is useful in disclosing metastatic ML from a variety of neoplasms. Due to its safety and accuracy profile, it should be considered the test of choice in evaluating abnormal ML in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic ultrasound guided pancreatic pseudocyst drainage (EUS-PPD) is increasingly being used for management of pancreatic pseudocysts. We evaluated the outcome and complications of EUS-PPD with modified combined technique by inserting both endoprosthesis and naso-cystic drain. Methods: Forty patients referred between August 2007 and January 2010 for EUS-PPD were prospectively studied. EUS-PPD was attempted for symptomatic pancreatic pseudocysts which were; (i) resistant to conservative treatment, (ii) in contact with the gastric or duodenal wall on EUS and (iii) having no bulge seen on endoscopy. Controlled radial expansion wire guided balloon dilation of the puncture tract was performed followed by insertion of a 10 French double pigtail stent and 7-Fr naso-biliary drain. The early and late outcome and complications of EUS-PPD were analyzed. Results: Thirty-two patients had non-infected and eight had infected pseudocysts. EUS-PPD was technically successful in all. Pseudocysts resolved completely in 39 patients, while one with infected pseudocyst underwent surgical resection for bleeding in the cyst. Naso-cystic drain was removed in 39 patients after median duration of 13 days. Thereafter, the double pigtail stent was removed in all cases after median duration of 10 weeks. Pseudocyst recurred in one patient requiring a second session of EUS-PPD. All 32 patients without cystic infection were successfully treated by EUS-PPD. Seven out of eight patients (87%) with cystic infection were successfully treated by EUS-PPD. Conclusion: Endoscopic ultrasound guided pancreatic pseudocyst drainage with modified combined technique is safe and is associated with high success rate. [ABSTRACT FROM AUTHOR]

Background and Aims: A prolific trend currently designates endoscopic ultrasonography (EUS) literature. We aimed to record all EUS-studies published during the past decade and evaluate them in terms of scientific quality, creating a stratification based on levels of evidence (LE). Methods: All articles on EUS published between January 2001 and December 2010 were retrieved using a Pubmed and Cochrane Library search. Inclusion criteria were: original research papers (randomized controlled trials-RCTs, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS. Levels of evidence (LE) were assessed using the North of England evidence-based guidelines. Results: Overall, 1,832 eligible articles were reviewed. The majority (46.1%) of reports comprised retrospective descriptive studies (LE III). Expert reviews and committee reports (LE IV) accounted for 28.9%, well-designed quasi-experimental studies (LE IIb) for 20.1%, RCTs (LE Ib) for 2.4%, prospective controlled trials (LE IIa) for 1.4%, and meta-analyses (LE Ia) for 1.1% of the total. High LE (Ia-Ib) were assigned to loco-regional staging of luminal gastrointestinal cancers; mediastinal staging of lung cancer; diagnostic work-up of solid pancreatic tumors, suspected biliary obstruction and choledocholithiasis; celiac plexus neurolysis; and pancreatic pseudocysts drainage. Intermediate to low LE (IIa-IV) were assigned to submucosal tumors, pancreatic cysts, chronic pancreatitis and novel therapeutic applications (pancreato-biliary drainage, tumor ablation). Conclusions: Diagnostic and staging EUS has matured and has proven its clinical impact on patient management. Therapeutic or interventional EUS is still evolving and more quality research and data are needed to establish EUS as the best next intervention to perform once firm evidence is available. [ABSTRACT FROM AUTHOR]

Background/Aim: To determine the yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in combination with immunostains in diagnosing unusual solid pancreatic masses (USPM) in comparison with pancreatic adenocarcinoma (ACP). Patients and Methods: All EUS-FNA of solid pancreatic masses performed with a 22-gauge needle were included. Data on clinical presentations, mass characteristics, presence of pancreatitis, yield of tissue, and final diagnosis were compared between the two groups. On site cytopathology was provided and additional passes were requested to perform immunostains. Results: Two hundred and twenty-nine cases with either adenocarcinoma or USPM were included. The median age of the cohort was 65 years. ACP (210/229, 92%) accounted for the majority of the cases. The USPM included neuroendocrine (NET) masses (n=13), metastatic renal carcinoma (n=3), metastatic melanoma (n=1), lymphoma (n=1), and malignant fibrous histiocytoma (n=1). Subjects with ACP were significantly more likely to present with loss of weight (P=0.02) or obstructive jaundice (P<0.001). Subjects with ACP were more likely to have suspicious/atypical FNA biopsy results as compared with USPM (10% vs 0%). The sensitivity of EUS-FNA with immunostains was 93% in ACP as compared with 100% in USPM. Diagnostic accuracy was higher in USPM as compared with ACP (100% vs 93%). Conclusions: EUS-FNA using a 22-gauge needle with immunostains has excellent diagnostic yield in patients with USPMs, which is comparable if not superior to the yield in pancreatic adenocarcinoma. [ABSTRACT FROM AUTHOR]

Background: In this retrospective study, we evaluated the prognostic effect of positive lymph-node ratio (pLNR) on patients with stage III colorectal cancer (CRC). Our paper is the first analysis, to our knowledge, to deal with such data from the Middle East. Methods: We analyzed the clinicopathological data of 535 patients diagnosed with colorectal cancer at our institution between 1983 and 2003. The 164 patients diagnosed with stage III disease were divided into two categories based on lymph-node ratio (LNR) being the ratio of positive lymph nodes over total lymph nodes dissected: LNR ≤0.4 and LNR >0.4. We used Kaplan-Meier and Cox proportional hazard models to evaluate the prognostic effect of pLNR. Results: The 10-year survival rate for the patients with stage IIIA, IIIB and IIIC cancers were 76%, 56% and 0% respectively (P = 0.014). Using pLNR of 0.4 as the cutoff point was found to yield clinically and significant results, with a significant difference in the outcomes of patients with pLNR ≤0.4 compared to those with pLNR >0.4 (hazard ratio = 5.25, 95% confidence interval = 1.2 to 22.1, P = 0.02). Conclusion: The ratio-based staging (pLNR) of CRC is a more accurate and clinically useful prognostic method than the number of positive LNs resected or the total number of LNs retrieved for predicting the course of patients with stage III CRC. [ABSTRACT FROM AUTHOR]

Placement of removable stents to close pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy has not been reported before. This case presents the feasibility of removable esophageal stent in closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Consecutive patients who underwent placement of removable esophageal stent for closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Three patients underwent successful stent placement in the hypopharynx. The stents were well tolerated. Patient one had the stent for 14 months, leading to complete healing of the fistula. Removal was successful. The second patient was palliated but died 8 weeks after stent placement. The third patient has successful palliation of his tracheo-esophageal fistula and the stent is being exchanged every 3-4 months to palliate his fistula. Closure of pharyngo-cutaneous and tracheo-esophageal fistulas is feasible with esophageal removable stents. These stents provide alternative options when dealing with these challenging problems. [ABSTRACT FROM AUTHOR]

Introduction: Secondary malignancies and chronic end-organ sequelae are significant and steadily rising consequences of cancer therapy. The workup and management of a carcinoma of unknown primary must consider the patient's clinical presentation, radiologic and pathologic findings, and comorbidities. Case Report: We present the case of a 50-year-old female survivor of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) with significant treatment-related end-organ sequelae who developed a metastatic adenocarcinoma of unknown primary 15 years following curative therapy for her ALL. The complex management issues related to the investigations and choice of therapy for this patient are reviewed. Discussion: This case discusses key issues related to the workup and management of a carcinoma of unknown primary. In addition, it illustrates the importance of taking patient comorbidities into consideration and tailoring investigations and therapy accordingly. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is third in cancer incidence and mortality, due in part to lack of awareness and low rates of screening. The purpose of the present study was to evaluate the efficacy of a spiritually based CRC educational intervention delivered by trained Community Health Advisors, in Alabama churches. The aim of the intervention was to increase knowledge and awareness of CRC and early detection, and to eventually increase CRC screening rates. Participants age-eligible for screening (N = 122) completed baseline, 6-month, and 12-month surveys by telephone. Increases in CRC knowledge, perceived benefits of CRC screening, and awareness of the screening modalities and decreases in perceived barriers to screening suggested that this type of intervention may be promising for CRC control and should be examined further. [ABSTRACT FROM PUBLISHER]

BACKGROUND: Mediastinal lymphadenopathy (ML) poses a great diagnostic challenge. OBJECTIVE: To investigate the predictors of malignancy in endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of ML in patients without known lung cancer. DESIGN: Retrospective study. SETTING: Tertiary referral center. METHODS: One hundred eight patients without known lung cancer who underwent EUS guided-FNA for ML between 2000 and 2007. All subjects underwent EUS-guided FNA. Data was collected on patients' demographics, and lymph node (LN) characteristics. Diagnosis of LN malignancy was based on FNA findings and clinical follow-up. RESULTS: One hundred eight patients were analyzed; 58 (54%) were men and 87 (79%) were Caucasian. Mean age was 55 years. Prior malignancy was present in 48 (43%) patients. A total of 126 FNA samples from 126 distinct LNs were performed. Twenty-five (20%) LNs were positive for malignancy. Mean short and long-axis for LNs were 13 and 29 mms respectively. Round shape and sharp borders were found in 29 (15%) and 25 (22%) LNs, correspondingly. Independent predictors of a malignant FNA were: Prior cancer (OR 13.10; 95% CI 2.7- 63.32; P = 0.001), short axis (OR 1.10; 95% CI 1.00-1.22; P = 0.041) and sharp LN borders (OR 5.47; 95% CI 1.01-29.51; P = 0.048). Age, race, gender, long axis, round shape were not associated with cancer in our cohort. LIMITATIONS: Retrospective design and lack of surgical gold standard. CONCLUSIONS: Increased risk of malignancy was associated with prior history of cancer, larger LN short axis and presence of LN sharp borders. These predictors may help guide endoscopists perform FNA in malignant LNs, increasing the overall efficiency of EUS-FNA for ML. [ABSTRACT FROM AUTHOR]

Background/purpose: Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that can often be difficult to distinguish from pancreatic cancer. We describe the clinical and radiographic features of 23 patients with AIP whose presentations mimicked pancreatic cancer. Methods: A review of clinic, radiology, and endoscopy records from a 6-year period identified patients with AIP initially suspected of having pancreatic cancer. Abdominal computed tomography (CT) with intravenous contrast, endoscopic ultrasonography (EUS), and/or ERCP was performed in each patient. The diagnosis of AIP was made histologically and/or cytologically for each patient. Results: Nineteen of 23 patients (83%) presented with new-onset weight loss, jaundice, or both. Nineteen (83%) patients had CT findings worrisome for pancreatic cancer including: (1) pancreatic enlargement or focal mass, (2) regional lymphadenopathy, and/or (3) vascular invasion. Eighteen patients (78%) had common bile duct strictures on ERCP. EUS-guided fine-needle aspiration biopsies excluded pancreatic cancer in all 22 patients who had EUS (96%). Seven patients had surgery for continued suspicion of pancreatic cancer. Conclusions: Although AIP commonly presents with features suggestive of pancreatic cancer, clinical recognition of AIP with appropriate diagnostic testing including EUS with fine-needle aspiration, ERCP, IgG4 levels, and pancreatic protocol CT expedites diagnosis and can spare patients unnecessary surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the evaluation of spindle cell and mesenchymal lesions is unclear. This study reviews the use of EUS-FNA in diagnosing intrathoracic and intra-abdominal spindle and mesenchymal cell lesions at an academic institution. METHODS. All EUS-FNA specimens with a significant spindle or mesenchymal cell component were retrieved. Follow-up was comprised of clinical correlation, chart review, or evaluation of subsequent tissue specimens, including FNAs, biopsies, and/or surgical resections. Lesions were categorized as either inflammatory/reactive or neoplastic. RESULTS. Forty-four EUS-FNA specimens were retrieved from 39 patients (21 men and 18 women with a median age of 61 years [range, 20-88 years]). Anatomic sites included 19 lymph node specimens, 15 gastrointestinal tract specimens, 7 pancreatic specimens, and 4 other anatomic site specimens. Twenty-two cases were inflammatory/reactive lesions, including 17 granulomatous lesions and 5 cases of chronic pancreatitis. Twenty-two cases were neoplastic, including 14 gastrointestinal stromal tumors, 2 smooth muscle tumors, 2 sarcomatoid carcinomas, 2 melanomas, 1 sarcoma, and 1 solitary fibrous tumor. A specific cytologic diagnosis was rendered in 30 cases (81%). Immunocytochemistry was performed on 21 neoplastic cases and contributed to the differential diagnosis in 18 cases. No false-positive findings were encountered. Three false-negative results were identified and were attributed to sampling error. CONCLUSIONS. Spindle cell neoplasms are rarely encountered on EUS-FNA. The differential diagnosis encompasses a wide variety of benign and neoplastic entities. Correlation of cytomorphology and ancillary studies yields a high diagnostic accuracy of spindle cell and mesenchymal lesions on EUS-FNA. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) has been described as a viable alternative to percutaneous transhepatic cholangiography (PTC) in patients in whom ERCP has been unsuccessful. The purpose of our study was to assess the utility of EUSBD using a newly released, fully covered, self-expanding, biliary metal stent (SEMS) for palliation in patients with an obstructing malignant biliary stricture. Methods: We collected data on all patients who presented with obstructive jaundice and who underwent transduodenal EUSBD after a failed ERCP. Eight patients presented with biliary obstruction from inoperable pancreatic cancer or cholangiocarcinoma. Reasons for failed ERCP were duodenum stenosis, high-grade malignant stenosis of the common bile duct, periampullary tumor infiltration, failure to access the common bile duct, and periampullary diverticulum. EUS was used to access the common bile duct from the duodenum after which a guidewire was advanced upwards toward the liver hilum. The metal stent was then advanced into the biliary tree. Technical success was defined as correct stent deployment across the duodenum. Clinical success was defined as serum bilirubin level decreased by 50% or more within 2 weeks after the stent placement. Results: Technical and clinical success was achieved in all eight patients. No stent malfunction or occlusion was observed. Complications included one case of duodenal perforation, which required surgery, and one case of self-limiting abdominal pain. Conclusions: EUSBD with a fully covered SEMS in whom ERCP is unsuccessful is effective for palliation of biliary obstruction. The limitations of our study are that we had a small number of patients and a limited follow-up time. [ABSTRACT FROM AUTHOR]

A forward-viewing echoendoscope (FV-CLA) has been recently developed for performing interventional endoscopic ultrasound (EUS). The role of FV-CLA in performing standard EUS-guided fine-needle aspiration (FNA), Tru-cut biopsy (TCB), and celiac plexus neurolysis (CPN) is unknown. Our aims were to evaluate the feasibility of the FV-CLA for performing EUS-guided FNA/TCB and CPN. In this prospective study conducted over a 3-month period, 30 patients were evaluated with the FV-CLA. Procedures performed were FNA in 28 lesions, TCB in one, and CPN in five patients. EUS-guided FNA was undertaken at the following sites: mediastinum ( n = 3), liver ( n = 2), retroperitoneal mass ( n = 2), pancreas head/uncinate ( n = 9), pancreas body ( n = 6), pancreas tail ( n = 4), and perigastric lymph node ( n = 2). The median size of the lesions was 37 × 34 mm. A median of two passes was performed (range: 1-7). Final cytopathology diagnosed malignancies in 21 patients, with adenocarcinoma suspected for one.TCB of a mediastinal lymph node revealed lymphoma. FNA was benign in six patients. The sensitivity, specificity, positive predictive value, and negative predictive value for a malignancy diagnosis was 96% (95% confidence interval [CI], 87-96%), 100% (95% CI, 70-100%), 100% (92-100), and 86% (60-86%), respectively. CPN was successful in all five patients. It was easier to deploy the needle from the echoendoscope at all locations, including the duodenum, and irrespective of the site of the lesion. The initial evaluation and safety profile of the FV-CLA echoendoscope for performing standard FNA/TCB and CPN appear to be favorable. The narrow image does not preclude basic therapeutic maneuvers. A major advantage appears to be easy needle deployment at any site within reach of the echoendoscope. [ABSTRACT FROM AUTHOR]

Background and Aims: Few case series are reported on endoscopic ultrasound (EUS)-guided drainage of pelvic abscesses under fluoroscopy guidance. We hypothesized that EUS-guided drainage of pelvic abscesses without fluoroscopy is an effective alternative to surgery in patients whose abscesses are not amenable to percutaneous drainage techniques. The aim of this study is to evaluate the clinical efficacy of EUS-guided trans-rectal/transcolonic drainage of pelvic abscess without fluoroscopy. Methods: Fourteen consecutive patients with pelvic abscesses not amenable to percutaneous drainage underwent EUS-guided drainage over a period of 22 months. Main outcome measures were the resolution of the pelvic abscess on repeat imaging and improved clinical symptoms. Results: Fourteen consecutive patients were enrolled. EUS-guided aspiration was performed in three patients. In two patients, dilatation and aspiration was performed, while trans-rectal stent was placed in nine patients. All patients became afebrile within 72 h. Stent was removed in all patients, after confirming the resolution of the abscess on repeat computed tomography after 7 days. One patient in whom only aspiration was done had recurrence of fever and abscess on the seventh day and was treated by surgical drainage. A follow-up EUS done in 13 of the patients after 3 months revealed no recurrence, and all patients were asymptomatic at 6 months. The procedure was uneventful in all patients. Conclusion: Endoscopic ultrasound-guided drainage without fluoroscopy is a safe and effective modality of treatment for pelvic abscesses not amenable to radiologically guided drainage, thus reducing the need for surgical intervention. [ABSTRACT FROM AUTHOR]

Screening is available and effective in colorectal cancer (CRC) control, but underutilized. The purpose of this study was to use focus group data to develop recommendations for the development of educational interventions to increase CRC screening, using an audience segmentation strategy. Demographic segments were based on urban--rural residence, race (African- American, White) and sex. One hundred and sixty-five participants age 501, with no history of CRC participated in 17 focus groups in Alabama urban and rural communities. Transcripts were examined by independent coders. Knowledge among participants was limited regarding age to begin screening, insurance coverage and risk factors for CRC. Perceived barriers to screening included lack of physician recommendation, cost/lack of insurance coverage, pain/discomfort and embarrassment. African-American men reported postponement in seeing their physicians. White women were proactive at initiating discussion of CRC screening with their providers while African-American women felt that providers should drive the process. No urban--rural differences were identified. This study identified cultural and gender characteristics and perceptions that can be used in the development of demographically segmented health communication interventions to increase CRC awareness and screening. [ABSTRACT FROM AUTHOR]

This study describes the development of a spiritually based intervention to increase colorectal cancer screening through African American churches by framing the health message with spiritual themes and scripture. The intervention development phase consisted of ideas from an advisory panel and core content identified in focus groups. In the pilot-testing phase, prototypes of the intervention materials were tested for graphic appeal in additional focus groups, and content was tested for acceptability and comprehension in cognitive interviews. Participants preferred materials showing a variety of African Americans in real settings, bright color schemes, and an uplifting message emphasizing prevention and early detection. Spiritual themes such as stewardship over the body, being well to serve God, and using faith to overcome fear, were well received. The materials were then finalized for implementation and will be used by community health advisors to encourage screening. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Internally fully covered self-expandable metal stents (FCSEMSs) have recently become available offering the possibility of removal. However, to our knowledge, the feasibility, techniques for endoscopic removal, and tissue reaction to FCSEMS have not been reported in humans. Our aims are (1) to report reasons for and success of FCSEMS removal in consecutive patients, (2) to describe methods of esophageal stent retrieval, and (3) to describe stent reactions induced by FCSEMS in humans.METHODS:Removable FCSEMSs (ALIMAXX-E, Alveolus Inc., Charlotte, NC) were placed in consecutive patients requiring palliation of dysphagia symptoms with locally advanced esophageal or gastro–esophageal junction cancers, refractory benign esophageal strictures, postoperative mediastinal leaks, or tracheoesophageal fistulas. Dysphagia scores were assessed at 1, 3, and 6 months. Esophagogram and endoscopy follow-up were performed routinely at 1 month or to assess new symptoms.RESULTS:A total of 36 stents were placed in 31 patients over 16 months (mean age 62.8 years, 61% white, 58% male). Indications included the following: malignant strictures (n=17), refractory benign strictures (n=7), tracheoesophageal fistulas (n=8), postoperative mediastinal leaks (n=2), and iatrogenic perforations (n=2). Dysphagia scores improved (decreased) significantly at 1 (mean difference 2.09; 95% confidence interval (CI) 1.65–2.52, P=0.0001), 3 (mean difference 2.1; 95% CI 1.57–2.62, P=0.0001), and 6 months (mean difference of 2; 95% CI 1.28–2.73, P<0.0001). Clinical success rates for various indications were: malignant strictures 88%, refractory benign strictures 29%, tracheoesophageal fistula 88%, postoperative mediastinal leaks 100%, and iatrogenic perforations 50%. Sixty one percent (n=22) of the stents were removed (removal was successful in 100% of cases attempted). Twenty three percent (n=5 stents in four patients) were removed due to chest pain or abdominal pain. The stents satisfied their purposes in all of these four patients. The remainder were removed on schedule or had satisfied their purpose and/or migrated. Fifty percent of removed stents had ulcers (median size=2 cm) at the distal edge of the stent, whereas 23% had ulcers at the proximal edge of the stent. Pseudo-polyps formed at either the proximal or distal edge of the stent in four patients. Tissue reaction was severe in only two patients. Stents were embedded in four cases but were easily lifted from tissue. Our preferred method of retrieval was the double-channel therapeutic endoscope with two rat-tooth forceps or rat-tooth forceps with a snare.CONCLUSIONS:FCSEMSs palliate dysphagia from both benign and malignant conditions and seal postoperative tracheoesophageal fistulas and mediastinal leaks. Tissue reaction to the stents was common but remained clinically insignificant in the majority of patients. Close follow-up of patients with FCSEMS is required and repeat endoscopy with stent retrieval might be necessary with the development of new symptoms or complications from the stent.Am J Gastroenterol 2009; 104:1374–1381; doi:10.1038/ajg.2009.133; published online 28 April 2009 [ABSTRACT FROM AUTHOR]

This study examined colorectal cancer (CRC) knowledge and the relationship between knowledge, risk factors and screening behaviors among African Americans and Whites in the Deep South. One hundred and twenty three African Americans and Whites age-eligible for CRC screening were interviewed by telephone survey as part of a church-based CRC educational intervention. CRC knowledge was lower among those with less education, unemployed, Medicaid, Medicare, and less family income. Generally, participants who had more CRC knowledge were more likely to have engaged in screening behaviors. Participants who had a family history of CRC were more likely to have had a fecal occult blood test (OR = 2.55, 0.99–6.60) or barium enema (OR = 3.84, 1.44–10.24) than those without. Whites were more likely to have had a flexible sigmoidoscopy (OR = 4.17, 1.09–16.67), colonoscopy (OR = 7.14, 1.72–25) or barium enema (OR = 6.25, 1.67–25) than African Americans. Church-based CRC screening intervention programs should target African Americans, those with no family history of CRC, and those with less education. [ABSTRACT FROM AUTHOR]

OBJECTIVES: With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS. METHODS: All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded. RESULTS: A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures ( n = 331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01 - 0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days, respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure. CONCLUSIONS: CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS. [ABSTRACT FROM AUTHOR]

Background: It is currently unknown whether a newly developed endoscopic ultrasound (EUS) program can produce results similar to those of experienced EUS centers. We therefore prospectively evaluated the diagnostic accuracy and major complications of EUS-guided fine needle aspiration (EUS-FNA) in a newly developed EUS program. Methods: All procedures were performed by a single endosonographer in the presence of a cytopathologist. Reference standard for classification of final disease included: surgical resection, death from disease progression and repeat radiologic and/or clinical follow-up. Major complications were defined as oversedation, and those that resulted in a physician or emergency department visits, hospitalization, or death. Results: 540 patients (median age 63 years, 77% white) underwent EUS-FNAs of 656 lesions: lymph nodes (LNs, n = 248), solid pancreatic masses (SPMs, n = 229), cystic pancreatic masses (CPM, n = 57), mural lesions (n = 41), bile duct/gallbladder (n = 28), liver (n = 17), mediastinum/lung (n = 17), adrenal (n = 15), spleen (n = 3) and kidney (n = 1). SPMs and bile duct/gallbladder lesions were more likely to have suspicious/atypical cytology when compared to other lesions (8.7 vs. 4.6%; p = 0.04) and required more passes to achieve a tissue diagnosis (p < 0.001). The overall sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA was 91.7, 97.1, 98.1, 87.7 and 93.8%, respectively. Six patients (1.1%) (95% CI 0.4–2.4) experienced a major complication. One patient died shortly after the procedure due to preexisting pulmonary embolus (0.18%). Conclusion: EUS-FNA is highly accurate and safe in sampling a variety of peri-intestinal organs and lymph nodes. With adequate third-tier training, a newly developed program can produce results similar to those from expert EUS centers. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS) has emerged as an excellent tool for the imaging of the gastrointestinal wall and surrounding structures. EUS-guided fine needle aspiration has broadened the applicability of this tool by allowing tissue sampling of a variety of lesions within or accessible from the gastrointestinal (GI) tract. In particular, EUS became the test of choice for evaluating pancreatic cysts and mass lesions, biliary strictures and masses, abnormal adenopathy accessible from the GI tract, and GI submucosal lesions. There appears to be an increasing role for EUS in the staging of lung cancer, evaluating adrenal lesions and GI mesenchymal tumors. More recently, EUS has acquired a new dimension in interventional applications. This includes, but is not limited to, celiac plexus block and celiac neurolysis for the management of pain associated with chronic pancreatitis and locally advanced pancreaticobiliary malignancies, respectively. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The close proximity of the echoendoscope to the extrahepatic bile ductal system and its safety make endoscopic ultrasonography (EUS) an excellent method for examining the common bile duct (CBD). The aim of the present study was to compare EUS diagnostic performance for CBD stones with endoscopic retrograde cholangiography (ERC). Methods: A prospective series of our first 60 patients (65% women, average age 43 years) who were referred for ERC for suspicion of choledocholithiasis based on clinical, biochemical and cross-sectional imaging (ultrasonography [US] or computed tomography [CT]) data underwent radial EUS. EUS results were recorded as positive or negative for CBD stones before starting the ERC. All patients underwent ERC with a balloon sweep of the bile duct as the standard of reference for CBD stone. All procedures were performed during the same endoscopy session by a single endoscopist who was blinded to the clinical, biochemical and imaging data. Results: Sixty-five percent of our patients had low to moderate risk for CBD stones. EUS diagnoses were confirmed by ERC as follows: 23 true positive, 33 true negative, three false negative and one false positive (sensitivity of 89%, specificity of 97%, positive predictive value of 96%, and negative predictive value of 92%; overall accuracy of 93%). Compared to the EUS diagnostic accuracy (90%) during the first 30 cases, EUS had a very high diagnostic accuracy (97%) for CBD stones during the last 30 cases ( P = 0.31). Conclusion: EUS is highly accurate for the diagnosis of choledocholithiasis. The EUS learning curve is relatively short for CBD stones. [ABSTRACT FROM AUTHOR]

Background and Aims: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a safe and accurate technique for diagnosing pancreatic cancer. The value of repeat EUS-FNA in patients with high clinical suspicion for pancreatic cancer after an inconclusive index study is unknown. Our aims were to determine the yield and success of repeat EUS-FNA and the reasons for failure of initial EUS-FNA. Methods: This was a retrospective analysis of prospectively collected data in a tertiary University based referral center for pancreatico-biliary disorders. All patients who underwent more then one EUS-FNA for evaluation of suspected pancreatic cancer over a five and a half year period were included in this analysis. Results: Of the 547 procedures performed on 517 patients, 24 (4.6%) patients underwent 51 repeat EUS-FNA procedures. Initial EUS-FNA was atypical/suspicious in 10 (41.6%), benign in 10 (41.6%), malignant in two (8.3%), and failed/indeterminate in two (8.3%) patients. Eight of 10 (80%) patients with atypical/suspicious findings at initial EUS-FNA were diagnosed with malignancy on repeat EUS-FNA. Of the 10 patients with benign findings at initial EUS-FNA, repeat study diagnosed two (20%) with malignancy and the rest were confirmed benign on long-term follow up (average 530 days, SD 369 days). Of the two patients with indeterminate findings at initial EUS-FNA, repeat study diagnosed one patient with malignant disease and the other with benign disease that was confirmed by long-term follow up. Of the two patients diagnosed with neoplastic disease at initial EUS-FNA, repeat EUS-FNA with immunostains downgraded both to chronic pancreatitis. Repeat EUS-FNA facilitated determination of the true status of disease in 20 of 24 patients (accuracy 84%). Suspected reasons for failed initial EUS-FNA were: coexisting pancreatitis ( n = 10; 42%), technical difficulty due to scope positioning in uncinate lesion/sedation failure ( n = 4; 16.7%), difficult cytology (partly cystic, extensive necrosis, well-differentiated adenocarcinoma) ( n = 4; 16.7%), presence of ascites or collaterals ( n = 3; 12.5%), pathologist's interobserver variation ( n = 2; 8.33%), and unknown reason in one patient. Conclusion: Repeat EUS-FNA is warranted in patients with high clinical suspicion for pancreatic cancer despite indeterminate or negative findings at initial EUS-FNA. [ABSTRACT FROM AUTHOR]

Background and Aims: Although numerous studies have evaluated outcomes pertaining to endoscopic retrograde cholangio-pancreatography (ERCP) complications, studies evaluating outcomes of management of post-ERCP pancreatitis are scant. This study evaluated the effectiveness of a standard treatment protocol in management of post-ERCP pancreatitis. Methods: This is a retrospective study of consecutive patients managed for post-ERCP pancreatitis, using a standard treatment protocol over a 3-year period. By protocol, patients received only intravenous fluids, narcotics, and analgesics for the first 24–72 h after admission. Oral intake was attempted when white cell count was normal or followed a downward trend, abdominal pain was absent or minimal without need for narcotics over a 12-h period, and serum lipase was less than three times normal range. For patients hospitalized beyond 72 h, an abdomen CT was obtained at days 4 and 10 to guide management. Intravenous antibiotics were administered only for patients with pancreatic necrosis. Jejunal feeding and a meperidine pump for pain control were initiated in symptomatic patients at day 4. Data on ERCP complications were collected prospectively and graded per consensus criteria. Effectiveness of the treatment protocol was evaluated by comparing clinical outcomes of patients managed by protocol versus those managed outside protocol. Results: 45 of 1976 patients (2.3%) who underwent ERCP developed post-ERCP pancreatitis. Of the 45 (female 31; mean age 43 years) patients, 32 were managed by protocol and 13 outside protocol. Protocol based management was associated with less severe disease as compared with those managed outside protocol (crude odds ratio (OR) = 11.2; 95% confidence interval (CI) = 1.9–68.7; P = 0.002). One patient managed outside protocol died of severe pancreatitis. When compared with those managed outside protocol, the median duration of hospital stay (7 vs 3 days; P = 0.01), the use of CT (100% vs 15.6%; P < 0.001), and the use of antibiotics (50% vs 3.1%; P = 0.01) were significantly lower in those managed by protocol. By multiple logistic regression, protocol-based management was associated with less severe disease (adjusted OR = 18.7; 95% CI = 2.6–132.1; P = 0.003) when adjusted for age, comorbidity, endotherapy and pancreatic stenting. Conclusions: A protocol-based management strategy was associated with less severe pancreatitis, shorter length of hospital stay, need for fewer imaging studies, and use of antibiotics. Prospective validation of these findings is justified. [ABSTRACT FROM AUTHOR]

Background and Aim: Although the role of intraductal ultrasound (IDUS) in the evaluation of specific disease entities is well known, its utility in evaluating indeterminate findings in a heterogeneous group of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is unknown. This study evaluates the diagnostic accuracy of IDUS in patients with indeterminate findings at ERCP. Methods: This was a prospective study of all patients who underwent IDUS for evaluation of an indeterminate biliary stricture or main pancreatic duct (MPD) dilation noted at ERCP over an 8-month period. The accuracy of IDUS was established based on long-term follow-up, surgery, or further investigations. Results: Twenty-nine (5%) of 600 patients who underwent ERCP had an indeterminate finding that warranted further evaluation by IDUS: this was biliary stricture in 19 patients and MPD dilation in 10. Technical success was 100%. Mean duration of follow-up was 435 days (range 192–614 days). In patients with biliary stricture, IDUS diagnosed 11 as benign and eight as malignant. In patients with MPD dilation, IDUS diagnosed intraductal papillary mucinous tumor in six patients and chronic pancreatitis in four. Findings on IDUS supported the correct diagnosis in 27 of 29 patients (93%). In two patients with dominant hilar stricture in the setting of primary sclerosing cholangitis, IDUS was false positive in one and false negative in the other. One patient died of multiorgan failure due to post-ERCP pancreatitis. Conclusions: A technically easy procedure, IDUS offers unique advantages in the evaluation of patients with indeterminate findings at ERCP. [ABSTRACT FROM AUTHOR]