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Background and Objectives: Previous reports assessing the reproducibility of endoscopic ultrasound elastography (EUS-E) in evaluation of solid pancreatic lesions (SPL) involved only experienced endosonographers. We aimed to assess the interobserver agreement (IOA) of EUS-E in the evaluation of SPL by endoscopists with different levels of experience in EUS and EUS-E., Materials and Methods: A cross-sectional observational multicenter study was designed and included 11 endoscopists who were divided into four groups: Group A (long experience in EUS and EUS-E); Group B (short experience in EUS and EUS-E); Group C (long experience in EUS and no experience in EUS-E); and Group D (no experience in EUS or EUS-E). The observers independently classified the patterns of 60 video sequences of EUS-E, after a 20-min training session. For each group, we calculated IOA (kappa statistic, k) of EUS-E and the diagnostic accuracy of EUS-E for pancreatic malignancy, by comparing the pattern of EUS-E indicative of malignancy (heterogeneous or homogenous blue) with the final diagnosis., Results: The overall IOA was moderate (k = 0.42; 95% confidence interval (CI) 0.33-0.52). The IOA of Group A (k = 0.80; 95% CI 0.65-1.00) was significantly higher than that of Groups B (k = 0.54; 95%CI 0.40-0.71), C (k = 0.54; 95%CI 0.39-0.68), and D (k = 0.28; 95%CI 0.14-0.40). IOA of Groups B and C was not significantly different, but it was significantly higher than that of Group D. The diagnostic accuracy of Group A (area under the curve under summary receiver operating characteristic (AUROC) = 0.83; 95%CI 0.75-0.90) was not significantly different from that of Group B (AUROC = 0.77; 95%CI 0.71-0.83), but it was significantly higher than that of Groups C (AUROC = 0.74; 95%CI 0.67-0.81) and D (AUROC = 0.74; 95%CI 0.67-0.81). No significant difference was seen between Groups B, C, and D for diagnostic accuracy., Conclusion: EUS-E is reproducible in the evaluation of SPL, even between endoscopists with no or limited experience in EUS and/or EUS-E. Reproducibility and diagnostic accuracy increase with experience in EUS and EUS-E.

Background: The role of EUS with contrast agents can be expanded through the use of time-intensity curve (TIC) analysis and computer-aided interpretation., Objective: To validate the use of parameters derived from TIC analysis in an artificial neural network (ANN) classification model designed to diagnose pancreatic carcinoma (PC) and chronic pancreatitis (CP)., Setting: Prospective, multicenter, observational trial-endoscopy units from Romania, Denmark, Germany, and Spain., Patients: A total of 167 consecutive patients with PC or CP., Interventions: Contrast-enhanced harmonic EUS (CEH-EUS) and EUS-guided FNA (EUS-FNA), TIC analysis, and ANN processing., Main Outcome Measurements: Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for EUS-FNA, CEH-EUS, and the ANN., Results: After excluding all of the recordings that did not meet the technical and procedural criteria, 112 cases of PC and 55 cases of CP were included. EUS-FNA was performed in 129 patients, and the diagnosis was confirmed by surgery (n = 15) or follow-up (n = 23) in the remaining cases. Its sensitivity and specificity were 84.82% and 100%, respectively, whereas the PPV and NPV were 100% and 76.63%, respectively. The sensitivity of real-time quantitative assessment of CEH-EUS was 87.5%, specificity 92.72%, PPV 96.07%, and NPV 78.46%. Peak enhancement, wash-in area under the curve, wash-in rate, and the wash-in perfusion index were significantly different between the groups. No significant differences were found between rise time, mean transit time, and time to peak. For the ANN, sensitivity was 94.64%, specificity 94.44%, PPV 97.24%, and NPV 89.47%., Limitations: Only PC and CP lesions were included., Conclusion: Parameters obtained through TIC analysis can differentiate between PC and CP cases and can be used in an automated computer-aided diagnostic system with good diagnostic results. (, Clinical Trial Registration Number: NCT01315548.)., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.

Background and Study Aims: Previous reports assessing the reproducibility of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) in the evaluation of solid pancreatic lesions (SPLs) involved mainly experienced endosonographers. We aimed to assess the interobserver agreement (IOA) of CH-EUS in the evaluation of SPLs by endoscopists with different levels of experience in EUS and CH-EUS., Participants and Methods: A cross-sectional observational multicenter study was designed and included 11 endoscopists who were divided into four groups according to their experience in EUS and CH-EUS: group A (long experience in EUS and CH-EUS); group B (short experience in EUS and CH-EUS); group C (long experience in EUS and no experience in CH-EUS); and group D (no experience in EUS or CH-EUS). The observers independently classified the patterns of 60 CH-EUS video sequences of 60 SPLs after a 20-minute training session. For each group, we calculated the IOA (kappa statistic, κ) of CH-EUS and the accuracy of CH-EUS for the diagnosis of pancreatic adenocarcinoma by comparing the pattern of CH-EUS indicative of pancreatic adenocarcinoma (hypo-enhanced contrast pattern) with the final diagnosis., Results: The overall IOA for CH-EUS was fair (κ = 0.32; 95 %CI 0.22 - 0.41). Group A (κ = 0.63; 95 %CI 0.45 - 0.85) had the highest IOA, followed by group C (κ = 0.54; 95 %CI 0.39 - 0.71), group B (κ = 0.38; 95 %CI 0.22 - 0.55), and group D (κ = 0.21; 95 %CI 0.07 - 0.36). The IOA of groups A and C was significantly higher than that of group D. No significant difference was seen between groups A, B, and C or between groups B and D in terms of IOA. Group A (area under the curve under summary receiver operating characteristic [AUROC] = 0.67; 95 %CI 0.58 - 0.75) had the highest accuracy for the diagnosis of pancreatic adenocarcinoma, followed by group C (AUROC = 0.58; 95 %CI 0.50 - 0.65), group B (AUROC = 0.55; 95 %CI 0.48 - 0.63), and group D (AUROC = 0.51; 95 %CI 0.43 - 0.58). The diagnostic accuracy of group A was not significantly different from that of group C, but it was significantly higher than that of groups B and D. No significant difference was seen between groups B, C, and D in terms of diagnostic accuracy., Conclusions: CH-EUS is reproducible in the evaluation of SPLs, even between endoscopists with no or limited experience in EUS and/or CH-EUS. Long experience in EUS is a major contributor to the IOA and diagnostic accuracy of CH-EUS.

Background and Study Aim: Poorly differentiated/high grade pancreatic ductal adenocarcinoma (PDAC) is associated with an early unfavorable outcome, and patients with these tumors may be candidates for neo-adjuvant treatment. Endoscopic ultrasound-guided pancreatic fine-needle biopsy (EUS-FNB) may, in theory, allow preoperative assessment of PDAC histological grading. The aim of the current study was to assess the interobserver agreement and accuracy of preoperative PDAC grading from EUS-FNB specimens., Methods: Data from 42 postsurgical PDAC patients who had undergone preoperative EUS-FNB were retrieved. Four experienced pathologists independently reviewed the EUS-FNB slides and reported tumor grading (well, moderately, or poorly differentiated). Agreement among pathologists for grading of preoperative EUS-FNB samples was expressed by using Cohen's or Fleiss' kappa statistic, as appropriate. Postsurgical PDAC grading was used as the gold standard to assess the cumulative accuracy of EUS-FNB for the preoperative prediction of PDAC grading., Results: The kappa values for PDAC grading on EUS-FNB specimens ranged from 0.09 to 0.41. The total agreement among the four pathologists was only fair (κ = 0.27; 95 % confidence interval [CI] 0.14 - 0.38). When tumor grades were grouped as well or moderately differentiated vs. poorly differentiated, kappa values ranged from 0.19 to 0.50, with only a fair overall agreement (κ = 0.27; 95 %CI 0.21 - 0.49). The accuracy of preoperative grading from EUS-FNB was 56 % (75/134 readings; 95 %CI 40 % - 65 %), with mean sensitivity and specificity to detect a high grade, poorly differentiated tumor of 41 % (95 %CI 19 % - 54 %) and 78 % (53/68 readings; 95 %CI 60 % - 99 %), respectively., Conclusions: Preoperative EUS-FNB-based histological grading of PDAC is unreliable, and current results do not support the use of this information in clinical practice. This appears to be due to suboptimal interobserver agreement among pathologists and an overall low accuracy in predicting postsurgical grading., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Diagnosis of pancreatic exocrine insufficiency (PEI) is hindered by methodological difficulties of pancreatic function tests. The probability of PEI in chronic pancreatitis (CP) increases as pancreatic fibrosis develops. Pancreatic fibrosis in CP may be quantified by EUS elastography., Objective: To evaluate whether EUS-elastography can predict PEI in patients with CP., Design: Prospective, observational study., Setting: Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain., Patients: Patients diagnosed with CP based on EUS and magnetic resonance imaging and MRCP findings., Interventions: Diagnosis of PEI was based on the (13)C-mixed triglyceride breath test. EUS-elastography was performed with PENTAX echoendoscopes and Hitachi-Preirus US platform. Two areas were selected for elastographic evaluation: area A corresponds to the pancreatic parenchyma and area B to a soft peripancreatic reference area. The quotient B/A (strain ratio [SR]) was considered the elastographic result., Main Outcome Measurements: Pancreatic SR in CP patients with and without PEI., Results: A total of 115 patients with CP (mean age, 50.2 years, range, 21-81; 92 male) of different etiologies were included; 35 patients (30.4%) had PEI. Pancreatic SR was higher in patients with PEI (4.89; 95% confidence interval, 4.36-5.41) than in those with a normal breath test result (2.99; 95% confidence interval, 2.82-3.16) (P < .001). A direct relationship was found between the SR and the probability of PEI, which increases from 4.2% in patients with an SR less than 2.5 to 92.8% in those with an SR greater than >5.5., Limitations: Single-center study., Conclusions: The degree of pancreatic fibrosis as measured by EUS-guided elastography allows quantification of the probability of PEI in patients with CP., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Endoscopic ultrasound (EUS) has become an essential tool for the study of pancreatic diseases. Specifically, EUS plays a pivotal role evaluating patients with a known or suspected pancreatic mass. In this setting, differential diagnosis remains a clinical challenge. EUS-guided fine-needle aspiration (FNA) and fine-needle biopsy (FNB) have been proven to be safe and useful tools in this setting. EUS-guided FNA and FNB, by obtaining cytological and/or histological samples, are able to diagnose pancreatic lesions with high sensitivity and specificity. In this context, several methodological features, trying to increase the diagnostic yield of EUS-guided FNA and FNB, have been evaluated. In this review, we focus on the role of rapid on-site evaluation (ROSE). From data reported in the literature, ROSE may increase diagnostic yield of EUS-FNA specimens by 10%-30%, and thus, diagnostic accuracy. However, we should point out that many recent studies have reported adequacy rates of > 90% without ROSE, indicating that, perhaps, at high-volume centers, ROSE may not be indispensable to achieve excellent results. The use of ROSE can be considered important during the learning curve of EUS-FNA, and also in hospital with diagnostic accuracy rates < 90%.

Endoscopic ultrasound (EUS) has evolved to become a crucial tool for the evaluation of pancreatic diseases, among them solid pancreatic lesions. However, its ability to determine whether a lesion is malignant or not is difficult to establish based only in the endosonographic image. EUS-guided fine needle aspiration (EUS-FNA) allows obtaining a cytological and/or histological sample from pancreatic lesions, with a high overall accuracy and low complication rates. Although the clinical usefulness of EUS-FNA for pancreatic diseases is widely accepted, the indications for tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic accuracy and complications of EUS-FNA, focusing on its current indications.

Background and Study Aims: Endoscopic ultrasonography (EUS) has become the method of choice for the diagnosis of chronic pancreatitis in clinical practice. However, the criteria allowing the specific diagnosis of the disease, mainly at non-advanced stages, are still under debate. Analysis of tissue stiffness by quantitative EUS-elastography may provide additional relevant information in this setting. The aim of this study was to evaluate the information provided by quantitative EUS-elastography for the diagnosis of chronic pancreatitis., Patients and Methods: A prospective, consecutive, 1-year study was designed, and included patients who underwent EUS for epigastric pain syndrome or known chronic pancreatitis. EUS-elastography was performed using radial Pentax EUS and Hitachi EUB900. The strain ratio was measured in the head, body, and tail of the pancreas, and the elastographic result was the mean of these three values. EUS criteria of chronic pancreatitis and the Rosemont classification were also evaluated. Data were analyzed by analysis of variance and linear regression; diagnostic accuracy was based on the receiver operating characteristic (ROC) curve analysis., Results: A total of 191 patients (mean age 52 years, range 21 - 85; 103 male) were included; 92 (48.2 %) of them were finally diagnosed with chronic pancreatitis. A highly significant direct linear correlation was found between the number of EUS criteria of chronic pancreatitis and the strain ratio (r = 0.813; P < 0.0001). The area under the ROC curve was 0.949 (95 % confidence interval 0.916 - 0.982) and the accuracy of EUS-elastography for diagnosing chronic pancreatitis was 91.1 % (cut-off strain ratio of 2.25). The strain ratio varied significantly in different Rosemont classification groups (P < 0.001)., Conclusions: EUS-elastography was an accurate tool for the diagnosis of chronic pancreatitis and provided relevant and objective information to support EUS findings., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The option of obtaining tissue samples for histological examination during endoscopic ultrasound (EUS) has theoretical and practical advantages over cytology alone. The aim of this study was to evaluate the feasibility, yield, and diagnostic accuracy of a new EUS 22-G fine-needle biopsy (FNB) device in patients with solid pancreatic masses in a multicenter, prospective study., Methods: All consecutive patients who underwent EUS-guided fine-needle biopsy (EUS-FNB) using a newly developed 22-G FNB needle between September 2010 and October 2010 were enrolled in the study. The EUS-FNB technique was standardized among the participating endoscopists. Only a single needle pass was performed., Results: A total of 61 patients (35 males, mean age 64.2 ± 12.4 years) with solid pancreatic masses with a mean size of 32.4 ± 8.5 mm (range 13-90 mm) participated. EUS-FNB was performed through the duodenum in 35 cases (57.4 %) and was technically feasible in all but one of the 61 (98.4 %) patients without complications. Tissue samples for histological examination were obtained from 55 patients (90.2 %) and were deemed adequate in 54 of the cases (88.5 %). The diagnoses established by EUS-FNB were adenocarcinoma (39 patients), neuroendocrine tumors (5), chronic focal pancreatitis (5), sarcoma (2), lymphoma (1), acinar cellular tumor (1), and pancreatic metastasis from renal cell carcinoma (1). In an intention-to-treat (ITT) analysis, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the histologic diagnosis of a pancreatic mass were 87.5, 100, 100, 41.7, and 88.5 %, respectively., Conclusions: EUS-FNB was technically feasible in 98 % of patients with a solid pancreatic mass. A suitable sample for histological evaluation was obtained in 88.5 % of the cases after only one single needle pass. The apparently low negative predictive value is likely to be improved by increasing the number of needle passes.

Aim: To evaluate the interobserver agreement among pathologists in grading the quality of specimens obtained with a new 19-gauge endoscopic ultrasound histology needle., Methods and Results: This multicentre prospective study involved 50 slides prepared using material obtained with the new needle. Five experienced pathologists independently reviewed all of the samples, and made assessments of the following features: the presence of a core, the adequacy of the specimen, the interpretability of the specimen, and the possibility of performing additional analyses using the material. Interobserver agreement, determined by Fleiss' kappa statistic and 95% confidence intervals (CIs), was used as the primary outcome measure. Overall, the presence of a core was reported in 88% of cases with good agreement among the pathologists (κ = 0.61; 95% CI 0.52-0.70). The specimens were adequate in 91.2% of cases, and Fleiss' κ was 0.73 (95% CI 0.61-0.81). The interpretation of the specimens was reported to be 'easy' in approximately 87% of cases, with moderate agreement among the pathologists (κ = 0.44; 95% CI 0.35-0.53). The possibility of performing additional analyses from the same sample was rated as positive in approximately 91%, with good agreement (κ = 0.66; 95% CI 0.58-0.75)., Conclusions: There was excellent interobserver agreement among pathologists in the assessment of the histological material, especially with regard to sample adequacy., (© 2012 Blackwell Publishing Ltd.)

Background: EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown., Objective: To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist., Design: Multicenter retrospective study., Setting: Public health system hospitals with experience in ESCP in Spain., Patients: A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures., Intervention: ESCP., Main Outcome Measurements: Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed., Results: A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula., Limitations: Retrospective study., Conclusion: Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Methods for evaluation of pancreatic exocrine insufficiency (PEI) are expensive, labor intensive, and not available at many institutions. The aim of this study was to investigate if PEI in chronic pancreatitis (CP) can by predicted by nutritional markers in blood., Methods: A retrospective analysis of a prospectively collected database of CP patients was performed. Diagnosis of CP was based on endoscopic ultrasonography or magnetic resonance imaging. PEI was investigated by the (13)C-mixed triglyceride breath test. Hemoglobin, mean corpuscular volume, lymphocytes, prothrombin time, and serum levels of total protein, albumin, prealbumin, retinol binding protein, cholesterol, triglycerides, amylase, folic acid, vitamin B12, HbA1C, transferrin, ferritin, magnesium and zinc were analyzed., Results: 114 patients were included in the study (97 males, mean age 48.1 years, 54 with alcohol etiology), 38 (33%) suffered from PEI. Magnesium below 2.05 mg/dL, hemoglobin, albumin, prealbumin and retinol binding protein below lower limit of normal and HbA1C above upper limit of normal were associated with PEI in univariate analysis. Magnesium below 2.05 mg/dL detected PEI with a sensitivity, specificity and positive and negative predictive values of 0.88 (95% confidence interval, 0.66-0.97), 0.66 (0.48-0.80), 0.58 (0.39-0.75) and 0.91 (0.73-0.98), respectively. The corresponding values were 1.00 (0.80-1.00), 0.55 (0.38-0.71), 0.52 (0.34-0.69) and 1.00 (0.82-1.00)) if one or more pathological tests among parameters significantly associated with PEI in was used as a positive test for PEI., Conclusion: Serum nutritional markers can be used to predict the probability of PEI in CP and provide guidance in decisions on enzyme replacement therapy., (Copyright © 2012. Published by Elsevier B.V.)

Endoscopic ultrasound (EUS) represents an advance in the diagnosis and staging of several diseases. EUS-guided fine-needle aspiration is useful, but technically demanding, and can be associated with complications. Elastography emerges as a useful tool that is based on the knowledge that some diseases, like cancer, lead to a modification in tissue stiffness. Elastography evaluates the elastic properties of tissues and compares images obtained before and after compression to target tissues; differentiating benign from malignant lesions. This article reviews theoretical aspects and the methodology of EUS elastography. Clinical applications, mainly in pancreatic diseases and lymph nodes, are analyzed., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Endoscopic ultrasound (EUS) is a reference technique for diagnosing and staging several different diseases. EUS-guided biopsies and fine needle aspirations are used to improve diagnostic performance of cases where a definitive diagnosis cannot be obtained through conventional EUS. However, EUS-guided tissue sampling requires experience and is associated with a low but not negligible risk of complications. EUS elastography is a non-invasive method that can be used in combination with conventional EUS and has the potential for improving the diagnostic accuracy and reducing the need for EUS-guided tissue sampling in several situations. Elastography measures tissue stiffness by evaluating changes in the EUS image before and after the application of slight pressure to the target tissue by the ultrasonography probe. Pathologic processes such as cancerization and fibrosis alter tissue elasticity and therefore induce changes in elastographic appearance. Qualitative elastography depicts tissue stiffness using different colors, whereas quantitative elastography renders numerical results expressed as a strain ratio or hue histogram mean. EUS elastography has been proven to differentiate between benign and malignant solid pancreatic masses, as well as between benign and malignant lymph nodes with a high accuracy. Studies have also demonstrated that the early changes of chronic pancreatitis can be distinguished from normal pancreatic tissues under EUS elastography. In this article, we review the technical aspects and current clinical applications of qualitative and quantitative EUS elastography and emphasize the potential additional indications that need to be evaluated in future clinical studies.

Background & Aims: By using strain assessment, real-time endoscopic ultrasound (EUS) elastography provides additional information about a lesion's characteristics in the pancreas. We assessed the accuracy of real-time EUS elastography in focal pancreatic lesions using computer-aided diagnosis by artificial neural network analysis., Methods: We performed a prospective, blinded, multicentric study at of 258 patients (774 recordings from EUS elastography) who were diagnosed with chronic pancreatitis (n = 47) or pancreatic adenocarcinoma (n = 211) from 13 tertiary academic medical centers in Europe (the European EUS Elastography Multicentric Study Group). We used postprocessing software analysis to compute individual frames of elastography movies recorded by retrieving hue histogram data from a dynamic sequence of EUS elastography into a numeric matrix. The data then were analyzed in an extended neural network analysis, to automatically differentiate benign from malignant patterns., Results: The neural computing approach had 91.14% training accuracy (95% confidence interval [CI], 89.87%-92.42%) and 84.27% testing accuracy (95% CI, 83.09%-85.44%). These results were obtained using the 10-fold cross-validation technique. The statistical analysis of the classification process showed a sensitivity of 87.59%, a specificity of 82.94%, a positive predictive value of 96.25%, and a negative predictive value of 57.22%. Moreover, the corresponding area under the receiver operating characteristic curve was 0.94 (95% CI, 0.91%-0.97%), which was significantly higher than the values obtained by simple mean hue histogram analysis, for which the area under the receiver operating characteristic was 0.85., Conclusions: Use of the artificial intelligence methodology via artificial neural networks supports the medical decision process, providing fast and accurate diagnoses., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Endoscopic ultrasound (EUS) has become an essential tool in the evaluation of pancreatic disease and can be considered the technique of choice for the diagnosis and staging of chronic pancreatitis (CP) and pancreatic cancer (PC). However, EUS has certain limitations, especially in the evaluation of patients with solid pancreatic masses (in the differential diagnosis of CP and PC). Furthermore there is variability in the EUS diagnostic criteria for CP. EUS-guided elastography is emerging as a highly useful tool in this setting. This modality has shown high diagnostic accuracy in the differential diagnosis of solid pancreatic masses, including differentiation between CP and PC. EUS-guided elastography has also been found to be useful in the diagnosis of CP, and can even classify patients according to the severity of their disease., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Objectives: The aim of this study was to evaluate the influence of on-site cytopathological evaluation on the diagnostic yield of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for the differential diagnosis of solid pancreatic masses in an unselected series of consecutive patients., Methods: Patients undergoing EUS-guided FNA of solid pancreatic lesions over a 2-year study period were included. Samples were either evaluated on site by a cytopathologist or processed by the endoscopist and sent to the pathology department for evaluation. Diagnostic accuracy for malignancy, number of needle passes, adequate-specimen collection rate, cytological diagnosis, and final diagnosis, and complication rate according to the presence or absence of on-site cytopathologist were evaluated., Results: A total of 182 patients were included. An on-site cytopathologist was available in 95 cases (52.2%). There was no difference between groups in terms of age, sex, location, and size of the lesions. A significantly higher number of needle passes was performed when an on-site cytopathologist was not available (3.5±1.0 vs. 2.0±0.7; P<0.001). The presence of an on-site cytopathologist was associated with a significantly lower number of inadequate samples (1.0 vs. 12.6%, P=0.002), and a significantly higher diagnostic sensitivity (96.2 vs. 78.2%; P=0.002) and overall accuracy (96.8 vs. 86.2%; P=0.013) for malignancy. Three patients developed complications (two acute pancreatitis, one local bleeding), all of them belonging to the group without on-site cytopathology., Conclusions: On-site cytopathological evaluation improves the diagnostic yield of EUS-guided FNA for the cytological diagnosis of solid pancreatic masses. This is associated with a significantly lower number of inadequate samples and a lower number of needle passes.

Background: EUS-guided FNA is an efficacious technique for sampling intraintestinal and extraintestinal mass lesions. However, cytology has limitations to its final yield and accuracy, which may be overcome if histological specimens are provided to the pathologist., Objective: To evaluate feasibility, yield, and diagnostic accuracy of a newly developed 19-gauge, fine-needle biopsy (FNB) device., Design: Multicenter, pooled, cohort study., Setting: Five medical centers., Patients: This study involved 109 consecutive patients with 114 intraintestinal or extraintestinal mass lesions and/or peri-intestinal lymph nodes., Intervention: EUS-guided FNB (EUS-FNB) with a newly developed, 19-gauge, FNB device., Main Outcome Measurements: Percentage of cases in which pathologists classified the sample quality as optimal for histological evaluation and the overall diagnostic accuracy compared with a composite criterion-standard diagnosis., Results: We evaluated 114 lesions (mean [± standard deviation] size 35.1 ± 18.7 mm; 84 malignant [73.7%] and 30 [26.3%] benign). EUS-FNB was technically feasible in 112 lesions (98.24%). Sample quality was adequate for full histological assessment in 102 lesions (89.47%). In 98 cases (85.96%), diagnosis proved to be correct according to criterion-standard diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for diagnosis of malignancy were 90.2%, 100%, 100%, 78.9%, and 92.9%, respectively., Limitations: Use of a surrogate criterion-standard diagnosis, including clinical follow-up when no surgical specimens were available, mainly in benign diagnoses., Conclusion: Performing an EUS-FNB with a new 19-gauge histology needle is feasible for histopathology diagnosis of intraintestinal and extraintestinal mass lesions, offering the possibility of obtaining a core sample for histological evaluation in the majority of cases, with an overall diagnostic accuracy of over 85%., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Introduction: Infections are the most frequent and severe complications of acute necrotizing pancreatitis with a mortality rate of up to 80 percent. Although experimental and clinical studies suggest that the microbiologic source of pancreatic infection could be enteric, information in this regard is controversial., Case Presentation: We describe a Citrobacter freundii isolation by endoscopy ultrasound fine needle aspiration in a 80-year-old Caucasian man with pancreatic pseudocyst after acute necrotizing pancreatitis., Conclusion: Our case report confirms that this organism can be recovered in patients with a pancreatic pseudocyst. On-site cytology feedback was crucial to the successful outcome of this case as immediate interpretation of the fine needle aspiration sample directed the appropriate cultures and, ultimately, the curative therapy. To the best of our knowledge, this is the first reported case of isolated pancreatic C. freundii diagnosed by endoscopy ultrasound fine needle aspiration.

Background & Aims: Qualitative endoscopic ultrasound (EUS) elastography is an accurate but subjective tool for the differential diagnosis of solid pancreatic masses. Second-generation EUS elastography allows quantitative analysis of tissue stiffness. We evaluated the accuracy of quantitative, second-generation EUS elastography in the differential diagnosis of solid pancreatic masses., Methods: The study included 86 consecutive patients who underwent EUS for the evaluation of solid pancreatic masses. EUS elastography was performed with the linear Pentax EUS and the Hitachi EUB900. Representative areas from the mass (A) and soft reference areas (B) were analyzed. The result of the elastographic evaluation was defined by the quotient B/A (strain ratio). Final diagnosis was based on histology of surgical specimens and cytology of EUS-fine-needle aspiration samples. The diagnostic accuracy of EUS elastography in detecting malignancy was calculated using receiver operating curve analysis., Results: The mean size of the pancreatic masses was 31.4 ± 12.3 mm. The final diagnoses were pancreatic adenocarcinoma (n = 49), inflammatory mass (n = 27), malignant neuroendocrine tumor (n = 6), metastatic oat-cell lung cancer (n = 2), pancreatic lymphoma (n = 1), and pancreatic solid pseudopapillary tumor (n = 1). The strain ratio was significantly higher among patients with pancreatic malignant tumors compared with those with inflammatory masses. The sensitivity and specificity of strain ratio for detecting pancreatic malignancies were 100% and 92.9%, respectively (area under the receiver operating curve, 0.983)., Conclusions: Quantitative, second-generation EUS elastography is useful for differential diagnosis of solid pancreatic masses. It allows for a quantitative and objective evaluation of tissue stiffness, which indicates the malignant or benign nature of the pancreatic lesion., (Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Differential diagnosis of solid pancreatic masses remains a challenge. EUS elastography, by analyzing tissue stiffness of the mass, may be of help in this setting., Objective: To evaluate the different elastographic patterns of solid pancreatic masses and the diagnostic accuracy of EUS elastography for malignancy., Design: Prospective, consecutive, descriptive study with a second blind evaluation of elastographic patterns for concordance analysis and use of a well-defined reference method for calculation of diagnostic accuracy., Patients: This study involved 130 consecutive patients with solid pancreatic masses and 20 controls with normal pancreases., Intervention: EUS elastography was performed by using a linear Pentax echoendoscope and Hitachi EUB-8500 US., Main Outcome Measurements: Elastographic patterns of solid pancreatic masses and accuracy of the technique for malignancy., Results: Mean (SD) size of the masses was 30.9 (12.5) mm. The final diagnosis was malignant tumor in 78 patients, inflammatory mass in 42 patients, and neuroendocrine tumor in 10 patients. Four elastographic patterns were described, with a high concordance among 2 blinded investigators. A green-predominant pattern, either homogeneous or heterogeneous, excluded malignancy with a high accuracy. On the contrary, a blue-predominant pattern, either homogeneous or heterogeneous, supported the diagnosis of malignant tumor. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of EUS elastography for diagnosis of malignancy were 100%, 85.5%, 90.7%, 100%, and 94.0%, respectively., Limitation: Single-center study., Conclusion: EUS elastography is a useful tool for differential diagnosis of solid pancreatic masses. It provides specific patterns supporting the benign or malignant nature of the disease.

Aim: To evaluate the diagnostic accuracy of histological evaluation of pancreatic tissue samples obtained by a modified method for recovering and processing the endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) material in the differential diagnosis of pancreatic solid masses., Methods: Sixty-two consecutive patients with pancreatic masses were prospectively studied. EUS was performed by the linear scanning Pentax FG-38UX echoendoscope. Three FNAs (22G needle) were carried out during each procedure. The materials obtained with first and second punctures were processed for cytological study. Materials of the third puncture were recovered into 10% formol solution by careful injection of saline solution through the needle, and processed for histological study., Results: Length of the core specimen obtained for histological analysis was 6.5 +/- 5.3 mm (range 1-22 mm). Cytological and histological samples were considered as adequate in 51 (82.3%) and 52 cases (83.9%), respectively. Overall sensitivity of both pancreatic cytology and histology for diagnosis of malignancy was 68.4%. Contrary to cytology, histology was able to diagnose tumours other than adenocarcinomas, and all cases of inflammatory masses. Combination of cytology and histology allowed obtaining an adequate sample in 56 cases (90.3%), with a global sensitivity of 84.21%, specificity of 100% and an overall accuracy of 90.32%. The complication rate was 1.6%., Conclusion: Adequate pancreatic core specimens for histological examination can be obtained by EUS-guided FNA. This technique is mainly useful for the diagnosis of different types of pancreatic tumours and evaluation of benign diseases.