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Ruben D. Acosta, MD, Neena S. Abraham, MD, MSCE, FASGE (invited content expert, ad-hoc member), Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, Dayna S. Early, MD, FASGE, Mohamad A. Eloubeidi, MD, MHS, FASGE, John A. Evans, MD, Ashley L. Faulx, MD, FASGE, Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE, Mouen A. Khashab, MD, Jenifer R. Lightdale, MD, MPH, FASGE, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, John R. Saltzman, MD, FASGE, Aasma Shaukat, MD, MPH, FASGE, Amandeep K. Shergill, MD, Amy Wang, MD, Brooks D. Cash, MD, FASGE, previous Committee Chair, John M. DeWitt, MD, FASGE, Chair

Background The currently accepted paradigm is that the false-positive (FP) rate for EUS-guided fine-needle aspiration (EUS-FNA) cytologic analysis of a pancreatic lesion is less than 1%. Objective To assess the FP rate of EUS-FNA in patients who underwent surgical resection for presumed pancreatic cancer. Design Retrospective study. Setting Tertiary-care referral center. Patients This study involved 367 patients with solid pancreatic lesions in whom EUS-FNA cytology results were interpreted as positive or suspicious for malignancy, which resulted in subsequent surgical resection. Intervention Surgical resection. Main Outcome Measurements The FP diagnosis was defined as EUS-FNA cytology specimens being reported as “positive” or “suspicious for malignancy” but that were later proven to be benign on surgical pathology. Results The FP rate for EUS-FNA was 4 of 367 (1.1%) when only “positive” cytology findings were interpreted as malignant and 14 of 367 (3.8%) when both suspicious and positive cytology findings were interpreted as malignant. Among the 4 cases falsely interpreted as positive, 1 was falsely diagnosed cytologically as a neuroendocrine tumor and 3 as adenocarcinomas. All FP specimens showed chronic pancreatitis on surgical pathology. The incidence of discordance between cytology and surgical pathology did not change over time (2000-2006: 8/188 [4.3%] vs 2007-2010: 6/179 [3.4%]; P = .79). Limitations Retrospective study at a single center. Conclusion In a retrospective cohort trial, the FP rate for EUS-FNA of solid pancreatic lesions was 1.1%. Findings of the current study are in line with previous studies that have evaluated the FP cytology rates with EUS-FNA of solid lesions. FP cases transpired primarily as a result of cytologic misinterpretation in the setting of chronic pancreatitis.

EUS-guided FNA of the left and right adrenals has been described, but data are very limited.Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement.Observational study.Tertiary referral center.Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach.Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 x 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (or =30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P.001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P.001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered.Lack of surgical criterion standard; 1 experienced endosonographer.EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.

Background EUS-guided FNA is a well-recognized technique for sampling the pancreas, peri-intestinal lymph nodes, and mass lesions. The role of EUS-guided FNA in the diagnosis of peritoneal carcinomatosis has not been well studied. Objective We aimed to determine the feasibility and success in sampling lesions in the peritoneum suspicious for carcinomatosis without a primary source. Design An observational study. Setting A tertiary referral center. Patients Consecutive patients who underwent EUS-guided FNA of peritoneal deposits. Results During a span of 3 years, 4 patients underwent transgastric or transduodenal EUS-guided FNA of peritoneal lesions with a curvilinear echoendoscope. All of these lesions were imaged by abdominal CT scan. The EUS findings of the nodules appeared round, relatively hypoechoic to the surrounding tissue, but hyperechoic when compared with the surrounding low-volume ascites where the lesions floated. Four passes were performed per case, and the diagnosis was achieved on a median of 2 passes (range 1-4). All patients received intravenous antibiotics during the procedure. Two patients had metastatic adenocarcinoma, 1 patient had lymphoma, and 1 patient had metastatic breast carcinoma. Diagnostic laparoscopy/laparotomy was avoided in all patients. No complications, particularly peritonitis, were encountered. Limitations Observational study with a small sample size. Conclusions Transgastric or transduodenal EUS-guided FNA for peritoneal carcinomatosis is feasible and safe. In the setting of an unknown primary cancer, EUS-guided FNA facilitates acquisition of tissues for treatment allocation, thus avoiding the need for laparoscopy or laparotomy.

Background EUS is being increasingly utilized for the diagnosis of choledocholithiasis and microlithiasis, especially in patients with biliary colic. Simultaneously, there is also a rising interest in the use of EUS for therapeutic interventions. Objectives Our goal was to assess the effectiveness of EUS-directed common bile duct (CBD) stone removal to compare its safety and effectiveness with ERCP-directed intervention. Design Interim results of a prospective, randomized, single-center blinded clinical trial. Setting A single tertiary care referral center. Patients Fifty-two patients with uncomplicated CBD stones were prospectively randomized to CBD cannulation and stone removal under EUS or ERCP guidance. Main Outcome Measurements and Interventions Primary outcome measure was the rate of successful cannulation of the CBD. Secondary outcome measures included successful removal of stones and overall complication rates. Results CBD cannulation followed by stone extraction was successful in 23 of 26 patients (88.5%) in the EUS group (I) versus 25 of 26 patients (96.2%) in the ERCP group (II) (95% CI, −27.65%, 9.88%). Overall, there were 3 complications in the EUS group and 4 complications in the ERCP group. Limitation The current study is an interim report from a single center report and performed by a single operator. Conclusions Our preliminary analysis indicates that outcomes following EUS-guided CBD stone retrieval are equivalent to those following ERCP. EUS-related adverse events are similar to those following ERCP. ERCP and EUS-guided stone retrieval appears to be equally effective for therapeutic interventions of the bile duct. Additional studies are required to validate these preliminary results and to determine predictors of success of EUS-guided stone removal.

Background Although the role of bedside endoscopy for the provision of emergent diagnosis and therapy is well known, the concept of bedside EUS requires further validation. Objective To evaluate the concept of bedside EUS and assess its impact on patient management. Design A prospective study. Setting A tertiary-referral center. Patients Patients included those with pancreaticobiliary and thoracic disorders who required EUS but who were clinically unstable to be evaluated in the endoscopy suite. Interventions All procedures were performed by one endosonographer at the patient's bedside by using an EUS cart that was equipped with a therapeutic curvilinear echoendoscope. Main Outcome Measurements To evaluate the technical feasibility, safety, and impact of bedside EUS in the clinical management of patients. EUS was considered to have a significant impact if a new diagnosis was established and/or if the findings altered subsequent management. Results Within a 3-month period, 6 patients (4 men; median age 56 years; American Society of Anesthesiologists class III/IV) were evaluated in the intensive care unit by using the mobile EUS cart. Procedural indications were the following: drainage of symptomatic pseudocyst (n = 2), evaluate the cause of cholangitis (n = 2), diagnose and treat a suspected postoperative (distal esophagectomy) fluid collection (n = 1), and provide tissue diagnosis in one patient with a pancreatic-head mass, who presented with intrahepatic bleeding. The procedure was technically successful in all 6 patients (100%), and no complications were encountered. Bedside EUS established a diagnosis of choledocholithiasis (n = 1), mediastinal abscess (n = 1), and pancreatic abscess (n = 1) in 3 patients, and ruled out the presence of choledocholithiasis (n = 1) and pancreatic pseudocyst (n = 1) in 2 other patients. Also, by using bedside EUS, transmural drainage of a pancreatic pseudocyst and mediastinal abscess was successfully undertaken in 2 patients. Bedside EUS had an impact on management in all 6 patients (100%): established a new diagnosis (n = 3), precluded the need for an ERCP and/or other interventions (n = 2), and enabled focused endotherapy (n = 3). Limitations Small number of patients; a single endosonographer. Conclusions Bedside EUS is technically feasible, safe, facilitates both diagnosis and therapy, and enables the clinical management of patients who are critically ill.

Background EUS-guided FNA is commonly performed to sample peri-intestinal targets such as the pancreas, lymph nodes, and the left adrenal gland. To our knowledge, EUS-guided FNA of the right adrenal gland has not been reported. Objective Our purpose was to determine the feasibility and success in sampling an enlarged right adrenal gland. Study Design Observational study. Setting Tertiary referral center. Patients Consecutive patients that underwent EUS-guided FNA of the right adrenal gland. Results Over a span of 3.5 years, 4 patients underwent transduodenal EUS-guided FNA of the right adrenal gland with a curvilinear echoendoscope. Four passes were performed in all cases, and the diagnosis was rendered on the first pass. The posterior wall of the descending duodenum was the port of entry of the needle. Three of the patients had metastatic lung cancer to the right adrenal gland; one was proven by surgical histopathologic examination. One patient had a benign aspirate consistent with angiomyolipoma. None of the patients had any minor or major complications. Limitations Observational study, small sample size. Conclusions Transduodenal EUS-guided FNA of the right adrenal gland is feasible and safe. Future large-scale studies are needed to replicate our findings and to determine the rate of successful identification and sampling of the right adrenal gland with the curvilinear echoendoscope.

Increasingly, peripancreatic fluid collections (PFCs) are managed endoscopically with conventional transmural drainage (CTD). The role of interventional EUS in drainage of PFCs requires further clarification, because the procedure is technically challenging, with limited availability.Identify characteristics that determine the need for drainage of PFC by CTD versus EUS.Consecutive patients with symptomatic PFCs (types: pseudocyst, abscess, and necrosis) referred for endoscopic drainage.Prospective study.Tertiary-referral center.After ERCP, transmural drainage was attempted by CTD. If unsuccessful, drainage by EUS was then attempted. Findings on contrast-enhanced CT and endoscopy were collected to identify characteristics that predict the need for CTD versus EUS drainage.Identify characteristics to determine whether CTD or EUS is best suited for drainage of a particular PFC. Technical outcomes and safety of both techniques were also compared.Of 53 patients with PFCs, CTD was technically successful in 30 (57%) and failed in 23 (43%). PFC regional location was the pancreatic head in 16, the body in 20, and the tail in 17; in these locations, CTD was successful in 13 (81%), 17 (85%), and 0, respectively. The causes of failed CTD were absence of luminal compression (LC) in 20, difficulty with scope positioning in 2, and bleeding with attempted drainage (portal hypertension) in 1. One PFC drained by CTD was later diagnosed as necrotic sarcoma. Of the 23 patients who failed CTD and underwent EUS, an alternate diagnosis of mucinous neoplasm was made in 2 patients, and EUS-guided drainage was successful in the other 21 patients (100%). Although CTD failed in all PFCs in the tail, all were successfully drained by EUS. In the pancreatic-head region, only those PFCs superior to pancreas and extending into porta hepatis (n = 3) required drainage by EUS. In the pancreatic body, only PFCs that developed bleeding from a transmural puncture or without definitive LC because of gastric mural edema (albumin1.5 mg/dL, n = 2) required EUS drainage. When compared with PFCs at other locations, those in the tail were best accessed by EUS (P.001). Patients with luminal compression at CT were significantly more likely to undergo successful drainage by CTD (adjusted odds ratio [OR] 13.6; P = .02). When compared with CTD, EUS drainages were longer in duration (40 versus 75 minutes; P.001), with similar rates of PFCs resolution (90% versus 95%). Although bleeding occurred in 1 patient in the CTD group, no complications were encountered in patients who underwent EUS-guided drainage. PFCs located at the tail of the pancreas were more likely to require drainage by EUS than CTD (adjusted OR 22.9, P = .003) when adjusted for the presence of luminal compression at CT, size of the PFC, serum albumin, and etiology of pancreatitis.Nonrandomized study.Because a majority of PFCs can be drained by CTD in a shorter duration, with comparable outcomes, EUS-guided drainage should be reserved mainly for PFCs located at the pancreatic tail, because these are unlikely to cause luminal compression or are technically difficult to access. Also, all pseudocyst-type PFCs must be evaluated by EUS before any attempts at endoscopic drainage, because EUS identifies an alternate diagnosis in 5% of such patients.

Background Studies that correlated EUS features of chronic pancreatitis (CP) with histopathology are retrospective and only include patients with severe disease or calcific pancreatitis. Controversies regarding the significance of EUS features of noncalcific CP (NCCP) remain unresolved. Objective To correlate EUS criteria for NCCP with histology from surgical specimens. Design Prospective study. Setting Tertiary referral center. Patients All patients who underwent EUS for pancreaticobiliary indications and subsequent pancreatic surgery. Patients with calcific pancreatitis were excluded. Methods Individual CP features on EUS were carefully documented with relation to different parts of the pancreas. Standard EUS criteria for CP were adopted. All patients underwent surgery within 2 months of EUS. A single pathologist blinded to EUS findings reviewed the specimens and graded fibrosis (total score, 12; ≥6 = unequivocal CP). A quantitative receiver operating characteristic (ROC) curve analysis was performed, and Spearman rank correlation coefficients were calculated. Main Outcome Measurements Correlate EUS criteria for NCCP, with histology from surgical specimens. Results Of the 42 patients evaluated, NCCP was diagnosed histologically in 21 patients (50%). None of the patients had CP diagnosis by CT. ROC curve analysis revealed that 4 or more EUS criteria provided the best sensitivity (90.5%), specificity (85.7%), and accuracy (88.1%) for diagnosing NCCP. Parenchymal EUS features that were significantly associated with histopathologic NCCP were foci ( P P P = .04); ductal features that were significantly associated with histopathologic NCCP were dilated ( P P P P = .03). There was a significant correlation between the number of EUS criteria and severity of NCCP on histology (r = 0.85; P Limitations Small number of patients. Conclusions An excellent correlation exists between EUS and histologic findings of NCCP.

OAE is commonly used. The majority of patients referred for OAE are considered appropriate for endoscopy according to ASGE guidelines. Most patients undergoing OAE procedures are knowledgeable about the study and are satisfied with the experience. Several potential problems have been identified, including inappropriate referrals, communication errors, and inadequately prepared or informed patients. OAE can be safely used if preprocedure assessment, informed consent, information transfer, patient safety, and satisfaction are addressed in all cases.

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett’s esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett’s esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

Background Diagnosing local recurrence of tumor after cystectomy and ileal conduit construction for urinary bladder cancer remains a diagnostic challenge. Also, distinction of benign stricture from recurrent tumor at the site of ureteral anastomosis in the ileal conduit is difficult. Objective A new method is described for performing EUS-guided FNA through the ileal conduit in patients suspected of having local tumor recurrence after complete cystectomy for bladder cancer. Design Case series, part of a large prospective study on EUS-guided FNA. Patients Three patients who had undergone total cystectomy and ileal conduit construction for bladder cancer underwent EUS-guided FNA through the ileal conduit for evaluation of suspected tumor recurrence at the site of anastomosis of the distal ureter and the ileal conduit. Main Outcome Measurements The feasibility, diagnostic accuracy, and safety profile of EUS-guided FNA is assessed. Observations EUS-guided FNA through the ileal conduit was technically feasible in all 3 patients. By EUS, the mass appeared as an irregularly shaped, hypoechoic lesion that was extrinsic to the lumen of the ileum. A diagnosis of recurrent transitional cell cancer was made in 2 patients and anastomotic stricture was found in 1 patient. Both patients with tumor recurrence received palliative chemotherapy, and the patient with an anastomotic stricture was managed by placement of a nephrostomy stent. No complications were encountered. Limitations Small number of enrolled subjects; short duration of follow-up. Conclusions EUS-guided FNA through the ileal conduit is technically feasible, safe, and establishes diagnosis in patients suspected of tumor recurrence after complete cystectomy for bladder cancer.

The relationship between hospital procedure volume and outcome has been recognized for various specialties and procedures. Although increasingly used and in existence for 40 years, to date, data on the relationship between hospital volume and outcome of ERCP are scant.We sought to examine health-related outcomes after ERCP in relation to hospital procedure volume.Secondary analysis of a national administrative database. We used the National Inpatient Sample (NIS) database to evaluate health-related outcomes among patients who underwent ERCP from 1998 to 2001.Logistic and multiple regression models were used to estimate the association of hospital ERCP volume with length of stay (LOS), rates of procedural failure, and mortality. Fixed effect models were used to adjust for all time invariant hospital characteristics for each hospital within the dataset.Data from 2629 hospitals that performed 199,625 ERCPs were evaluated. The median number of ERCPs performed in participating hospitals was 49 per year (range, 1-1004), with 25% of hospitals performingor =100 ERCPs per year and 5% performingor =200 per year. Significant trends in the relationship between volume and outcome were observed with respect to LOS and procedural failure: the median LOS was lower in high-volume (or =200 ERCP/y) than low-volume (or =100 ERCP/y) hospitals (6.9 vs 7.8 days, p0.0001) and the mean difference in expected LOS was 1.08 days (p0.0001). Multivariate regressions with hospital level fixed effects found significant negative relationships between procedure volume and procedure failure rates, but no significant effect on inpatient mortality rates was detected.NIS database permits analyses of only inpatient ERCPs. It precludes analysis of procedural complications, reinterventions, and influence of individual provider volume on outcomes.Inpatients who undergo ERCP at high-volume hospitals have shorter LOS and lower procedural failure rates than those undergoing ERCP at low-volume hospitals. These findings have important implications for health care policy decision making and resource utilization.

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p0.001). On multivariable analysis, age50 years (p0.001), male gender (p0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

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Background In patients with pancreatic cancer, the presence of malignant mediastinal lymphadenopathy (MML) would preclude definitive resection. A recent study suggested routine evaluation for mediastinal lymph-node metastases in all patients being evaluated for pancreaticobiliary masses. In our practice, we routinely assess for mediastinal lymph-node metastases in all patients undergoing EUS for pancreaticobiliary cancer. Methods We retrospectively evaluated the presence of MML by EUS-guided FNA (EUS-FNA) in 160 consecutive patients with a definite diagnosis of pancreaticobiliary cancer (pancreatic and periampullary cancers) who underwent EUS-FNA by a single operator from 2000 to 2004. Lymph nodes that were round and hypoechoic with sharp margins were considered suspicious and were sampled by FNA. Results Of the 160 patients included in this study, 78 had peripancreatic lymph nodes (49%: 95% CI[41%, 58%]), 25 had celiac lymph nodes (16%: 95% CI[10%, 22%]), and 14 patients had mediastinal lymph nodes (9%: 95% CI[4%, 13%]) that were suspicious for malignancy by morphologic criteria. In 8 of 14 patients with suspicious mediastinal lymph nodes, FNA documented MML in 5%: 95% CI[2%, 8%]. Only one of these 8 patients with MML had other sites of documented distant metastases by CT and/or positron emission tomography scans. However, 7 of 8 patients had locally advanced cancers. Conclusions MML is detected by staging EUS-FNA in 5% of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy.

Background The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. Methods A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. Results Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported ( p =0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. Conclusions EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

Background The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined. Methods All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers. Results Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (≥3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically. Conclusions EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.

Primary pancreatic cancer is the fourth leading cause of cancer-related death in the United States among both genders. 1 Metastases to the pancreas are less common. Osteosarcoma is a relatively uncommon malignancy, and metastases to the pancreas are even more rare. 2 To our knowledge, there are no cases that were diagnosed by EUS-guided FNA (EUS-FNA). We report a case of osteosarcoma metastatic to the pancreas diagnosed with EUS-FNA with positive on-site pathology evaluation.

Background: Many abstracts submitted to annual scientific meetings never come to full publication in peer-reviewed journals. The objective of this study was to determine factors associated with the fate of endoscopic research abstracts submitted to the annual scientific meeting of the American Society for Gastrointestinal Endoscopy (ASGE). Methods: All abstracts (n = 461) submitted to the annual meeting of the ASGE in May of 1994 were retrospectively reviewed. The following databases were searched for evidence of publication of abstracts in full-manuscript form: Medline, HealthSTAR, Current Contents, CINHAL, and Cancerlit. All abstracts were reviewed between May 4, 1998 and June 30, 1998. Univariate and multivariate analysis were performed to determine the association between abstract characteristics and acceptance for presentation at the meeting and for publication. Results: Fifty-five percent (247/451) of submitted abstracts were accepted for presentation. In univariate analysis, pediatric studies, prospective studies, randomized studies, and studies from university-affiliated medical centers (UAMC), were more likely to be accepted for presentation ( p p = 0.01), prospective studies ( p = 0.005), randomized studies ( p = 0.06), and studies from UAMC ( p = 0.01) predicted acceptance of abstracts for presentation at the meeting. The overall publication rate was 25.1%. The publication rates 1, 2, 3, and 4 years after the meeting were 6.7%, 16.2%, 22.8%, and 25.1%, respectively. Multivariate Cox proportional hazards analysis showed that accepted abstracts ( p = 0.0003) studies reporting positive results ( p = 0.0015), and studies from outside the United States ( p = 0.036) were more likely to be published in manuscript form. Conclusions: The overall publication rate of abstracts reporting endoscopic research is 25%, lower than that in any published report from other medical societies. Abstracts from the United States were less likely to be published in full-manuscript form. Although there was no positive outcome bias for acceptance of abstracts for presentation at the meeting, there was bias toward publication of statistically significant results. Further investigations are warranted to determine the variation in the publication of research results according to country of origin and to determine factors that hinder publication of GI endoscopic research in manuscript form. (Gastrointest Endosc 2001;53:275-82.)

Background and Aims EUS-guided FNA (EUS-FNA) is increasingly being used for tissue diagnosis of extrahepatic biliary strictures. The aim of this study was to determine the diagnostic yield of EUS-FNA in malignant biliary strictures. Methods A comprehensive literature review was carried out by 2 reviewers for studies evaluating the accuracy of EUS-FNA in biliary stricture. A meta-analysis was performed to determine the pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for EUS-FNA of extrahepatic biliary stricture. A Quality Assessment of Diagnostic Accuracy Studies questionnaire was used to assess the quality of the selected studies. Several sensitivity analyses were performed to assess the effect of the quality of the studies on the accuracy of the final results of the meta-analysis. Results Twenty studies involving 957 patients met inclusion criteria and were included in the meta-analysis. The pooled sensitivity and specificity of EUS-FNA for diagnosis of malignant biliary stricture were 80% (95% confidence interval [CI], 74%-86%), and 97% (95% CI, 94%-99%), respectively. The pooled positive likelihood ratio was 12.35 (95% CI, 7.37-20.72), and the negative likelihood ratio was 0.26 (95% CI, 0.18-0.38). The pooled diagnostic odds ratio for diagnosing a malignant biliary stricture was 70.53 (95% CI, 38.62-128.82). The area under the receiver-operating characteristic curve was 0.97. Sensitivity analyses showed that the quality of the included studies did not affect the accuracy of the final results of the meta-analysis. Conclusion This meta-analysis demonstrates that EUS-FNA is sensitive and highly specific for diagnosing malignancy in biliary strictures. Further studies are needed to compare EUS--FNA with emerging methods including cholangioscopy-guided biopsy and laser endomicroscopy.

Background The presence of debris within a pseudocyst may impair success of endoscopic drainage. Objective To compare the clinical outcomes and adverse-event rates of EUS-guided pseudocyst drainage with and without a nasocystic drain for the management of pancreatic pseudocysts with viscous solid debris-laden fluid. Design Retrospective study. Setting Single, tertiary-care referral center. Patients Consecutive patients with pancreatic pseudocysts managed by EUS-guided drainage: those with solid debris who underwent drainage via nasocystic drains alongside stents (n = 63) and those with solid debris who underwent drainage via transmural stents only (n = 24). Intervention Drainage via nasocystic drains alongside stents or drainage via transmural stents only. Main Outcome Measurements The primary outcomes were short-term success and long-term success of the procedures. The secondary outcomes were procedure-related adverse events and reintervention. Results The patients with viscous solid debris-laden fluid whose pseudocysts were drained by both stents and nasocystic tubes had a 3 times greater short-term success rate compared with those who had drainage by stents alone ( P = .03). On 12-month follow-up, complete resolution of pseudocysts with debris drained via stents alone was less (58%) compared with those with debris who underwent drainage via nasocystic drains alongside stents (79%; P = .059). The rate of stent occlusion was higher in cysts with debris drained by stents alone (33%) compared with those drained via nasocystic drains alongside stents (13%; P = .03). Limitations Retrospective design; limited sample size. Conclusion In patients with pseudocysts with viscous debris-laden fluid, EUS-guided drainage by using a combination of a nasocystic drain and transmural stents improves clinical outcomes and lowers the stent occlusion rate compared with those who underwent drainage via stents alone.

N M D U A 71-year-old man with a 7-year history of type II diabetes mellitus and a 7-kg weight loss was referred for EUS for an ill-defined mass in the head of the pancreas. Endoscopy and EUS showed a widely patent, mucinexuding ampulla of Vater (A and video, available online at www.giejournal.org) and a complex cystic mass in the head and uncinate of the pancreas. The cystic mass was ectatic dilation of the main pancreatic duct (12 mm, B, thin arrow), consistent with an intrapapillary mucious tumor of the pancreas (IPMN), which harbored ultiple mural nodules (B, asterisk). The complex cystic mass measured 67 50 mm. A triple-phase CT scan of the abdomen (C) showed lobulated macrocystic lesions involving the pancreatic head and uncinate process. A Whipple procedure was performed. Surgical pathology (D) showed primary and secondary pancreatic ducts

Background Intra-abdominal lymphadenopathy is a common diagnostic challenge faced by clinicians. In the absence of palpable peripheral nodes, tissue is usually obtained from the abdominal nodes by image-guided biopsy or surgery. We speculate that EUS-guided FNA (EUS-FNA) avoids the morbidity of a laparotomy and might be equally effective. Objective To evaluate the role of EUS-FNA in abdominal lymphadenopathy. Design Prospective study conducted over 42 months. Setting Tertiary care center in New Delhi, India. Patients Patients with abdominal lymphadenopathy in whom image-guided node biopsy failed were considered for EUS-FNA. Intervention A total of 3 passes were performed at each site. Slides were prepared per protocol and sent for cytopathologic evaluation. Results A total of 142 patients were enrolled, but only 130 (91.5%) underwent FNA. The mean lymph node size was 22 ± 3.2 mm; 71.8% of the nodes were hypoechoic (n = 102), and 28.1% were heterogeneous with an anechoic center (n = 40). In 120 patients (84.5%), the lymph nodes were intra-abdominal only, and in 22 patients (15.5%), they were both intra-abdominal and mediastinal in location. Main Outcome Measurement EUS-FNA was successful in establishing a diagnosis in 90.8% of these patients; 76.1% were found to have tuberculosis, 7.04% sarcoidosis, 6.33% Hodgkin's lymphoma, and 0.74% non-Hodgkin's lymphoma. Limitations In 8.4% patients, nodes were inaccessible because of their retropancreatic location. Conclusions EUS-FNA is a safe, accurate, and minimally invasive modality for diagnosing the cause of abdominal lymphadenopathy. In highly endemic areas, tuberculosis is the most common cause.

A 68-year-old man presented with painless jaundice without weight loss. Laboratory results revealed a total bilirubin of 9.1 mg/dL (0.4–1.4 mg/dL), lipase of 672 U/L (0–61 U/L), and CA 19-9 of 2 U/mL (≤36]. The aspartate aminotransferase and alanine aminotransferase levels were 142 U/L (15–40 U/L) and 320 U/L (5–58 U/L), respectively, and the alkaline phosphatase was 324 U/L (39–70 U/L). A CT scan demonstrated biliary dilation and a multicystic lesion in the pancreatic head. ERCP revealed a distal biliary stricture across which a stent was placed. Cytologic brushings demonstrated dysplastic features. EUS revealed that the pancreatic duct was dilated to 1 cm in the neck of the pancreas. In the head, there was a large 5-cm cystic lesion that contained a 2-cm hyperechoic mural nodule and a solid 2-cm hypoechoic component, which the biliary stent traversed (A). Smaller nodules emanated from the wall of the cyst in a popcorn-like fashion. Transduodenal FNA of the solid component was performed, and cytology revealed adenocarcinoma (B). The patient subsequently underwent pancreaticoduodenectomy. The surgical specimen revealed solid components and multiple cysts containing tan papillary material (C). Histology revealed exuberant intraductal papillae consistent with intraductal papillary mucinous neoplasm (IPMN) (D) and regions of high cellularity consistent with adenocarcinoma (E). Cells contained extensive granular eosinophilic cytoplasm (B, F), consistent with the unusual oncocytic type IPMN.

Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases.To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases.Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity.Two tertiary care centers with long-standing experience in the management of benign esophageal strictures.Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations.Temporary placement of FCSEMS until stricture resolution.Clinical response, efficacy, and morbidity.Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P.0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications.Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Background Tissue sampling of renal lesions is traditionally performed with percutaneous US or CT guidance. To date, only 3 known cases of EUS-guided FNA (EUS-FNA) of a renal mass have been reported. Objective To describe a multicenter experience with the indications, yield, and complications from attempted EUS-FNA of a kidney mass. Design Retrospective case series. Setting Six tertiary referral hospitals in the United States. Patients Consecutive subjects undergoing attempted EUS-FNA of a kidney mass. Endosonographers at 15 other teaching hospitals were contacted regarding EUS findings and follow-up of any EUS-guided renal biopsies previously attempted or considered at that institution. Interventions EUS-FNA of a kidney mass. Main Outcome Measurements Biopsy indications, yield, diagnosis, and complications. Results Fifteen procedures in 15 patients (9 men; median age 67 years) were performed at 6 (37%) of 16 hospitals (Indiana University plus 15 other hospitals). Kidney masses (median diameter 32 mm; range 11-60 mm) were located in the upper (n = 12) and lower (n = 3) poles of the left (n = 10) and right (n = 5) kidneys, respectively. Initial mass detection was by previous imaging in 13 (87%) patients or by EUS in 2 (13%) patients. Results of EUS-FNA (median 3 passes; range 2-4 passes) in 13 (87%) procedures were diagnostic of (n = 7) or highly suspicious for (n = 1) renal cell carcinoma (RCC), atypical cells (n = 2), oncocytoma (n = 1), benign cyst (n = 1), and nondiagnostic (n = 1). No complications were encountered. Surgical resection confirmed RCC in 7 patients in whom preoperative EUS-FNA demonstrated RCC (n = 5) or oncocytoma (n = 1) or was not performed (n = 1). Limitations Retrospective series, small number of patients. Conclusions EUS-FNA of renal masses is rarely performed at the U.S. teaching hospitals surveyed. This technique appears safe and feasible and should be considered when results would affect patient management.