Combined EUS with FNA and ERCP for the evaluation of patients with obstructive jaundice from presumed pancreatic malignancy

Combined Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in Patients With Malignant Distal Biliary Obstruction Is Associated With Reduced Time to Oncological Therapy Compared With ERCP and Sampling Alone

OBJECTIVES

Standard endoscopic retrograde cholangiopancreatography (ERCP) sampling techniques for pancreaticobiliary malignancy have modest yields that could lead to delays in treatment. We evaluated whether combining EUS-guided tissue acquisition (EUS-TA) with ERCP improved time to first outpatient evaluation and treatment.

MATERIALS AND METHODS

All patients without a prior pathological diagnosis who underwent index ERCP at Leeds Teaching Hospitals NHS Trust, United Kingdom, for malignant distal biliary obstruction from 2015 to 2020 were considered.

RESULTS

A total of 292 patients were included, of whom 74.7% (n = 202) underwent EUS-TA/ERCP. A combined approach was more likely to establish a positive diagnosis (96.5% [n = 195] vs 57.8% [n = 52], P < 0.01) and less likely to require further sampling procedures (2.0% [n = 4] vs 17.8% [n = 16], P < 0.01). Mean times to first outpatient evaluation (16.9 vs 24.5 days [ P = 0.01]) and oncological treatment (55.1 vs 79.3 days [ P = 0.03]) were significantly shorter. A third (n = 86) of patients with a positive diagnosis did not receive oncological/surgical treatment.

CONCLUSIONS

A combined approach was associated with improved yield and reduced time to evaluation/treatment, with similar success and adverse event rates. Careful multidisciplinary discussion is recommended to avoid performing unnecessary EUS procedures.

Same versus separate sessions of endoscopic ultrasound-guided fine-needle biopsy and endoscopic retrograde cholangiopancreatography for distal malignant biliary obstruction: a propensity score-matched study

BACKGROUND

Same-session endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) is an attractive policy for patients with distal malignant biliary obstruction (DMBO) requiring fine-needle biopsy (FNB) and biliary drainage. However, scanty and conflicting data exists regarding safety and efficacy when comparing these two procedures performed in same versus separate sessions.

METHODS

Single-center, retrospective, propensity score-matched study including patients with DMBO who underwent EUS-FNB followed by ERCP during the same or separate sessions. The primary outcome was the safety of the procedure [number of patients experiencing adverse events (AEs), overall AEs, its severity, post-ERCP pancreatitis (PEP)]. Secondary outcomes were successful ERCP, use of advanced cannulation techniques, EUS-FNB adequacy, length of hospital stay, overall procedure time, and time to recurrent biliary obstruction.

RESULTS

After propensity matching, 87 patients were allocated to each group. AEs developed in 23 (26.4%) vs. 17 (19.5%) patients in the same and separate sessions group, respectively (p = 0.280). The overall number, the severity of AEs, and the rate of PEP were similar in the two groups. Secondary outcome parameters were also comparable in the 2 groups.

CONCLUSIONS

Same-session EUS-FNB followed by ERCP with biliary drainage is safe and does not impair technical outcomes of tissue adequacy and biliary cannulation.

Influence of biliary stents on the diagnostic outcome of endoscopic ultrasound-guided tissue acquisition from solid pancreatic lesions: a systematic review and meta-analysis

BACKGROUND/AIMS

This meta-analysis analyzed the effect of an indwelling biliary stent on endoscopic ultrasound (EUS)-guided tissue acquisition from pancreatic lesions.

METHODS

A literature search was performed to identify studies published between 2000 and July 2022 comparing the diagnostic outcomes of EUS-TA in patients with or without biliary stents. For non-strict criteria, samples reported as malignant or suspicious for malignancy were included, whereas for strict criteria, only samples reported as malignant were included in the analysis.

RESULTS

Nine studies were included in this analysis. The odds of an accurate diagnosis were significantly lower in patients with indwelling stents using both non-strict (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.52-0.90) and strict criteria (OR, 0.58; 95% CI, 0.46-0.74). The pooled sensitivity with and without stents were similar (87% vs. 91%) using non-strict criteria. However, patients with stents had a lower pooled sensitivity (79% vs. 88%) when using strict criteria. The sample inadequacy rate was comparable between groups (OR, 1.12; 95% CI, 0.76-1.65). The diagnostic accuracy and sample inadequacy were comparable between plastic and metal biliary stents.

CONCLUSION

The presence of a biliary stent may negatively affect the diagnostic outcome of EUS-TA for pancreatic lesions.

Does same session EUS-guided tissue acquisition and ERCP increase the risk of pancreatitis in patients with malignant distal biliary obstruction?

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography-guided tissue acquisition (EUS-TA) are increasingly performed in the same session in patients with malignant biliary obstruction. In this retrospective analysis, we investigated adverse events (AE) after same session ERCP and EUS-TA.

METHODS

Patients with malignant distal biliary obstruction who underwent EUS-TA and/or ERCP with self-expandable metal stent (SEMS) placement from January 2015 to April 2020 were included. Primary outcome was post-procedural pancreatitis (PPP). Secondary outcomes were other procedure-related AE.

RESULTS

We included 494 patients, of which 118 patients (24%) underwent same session EUS-TA+ERCP, 51 patients (10%) underwent separate session EUS-TA & ERCP, 90 patients (18%) ERCP-only and 235 patients (48%) EUS-TA only. PPP occurred in 22 patients (19%) after same session EUS-TA+ERCP and in 6 patients (12%) after separate EUS-TA & ERCP (p = 0.270). When adjusted for other known risk factors (i.e., difficult procedure), the difference in PPP remained non-significant (adjusted odds ratio 1.74 (95%-CI 0.65-4.67, p = 0.268). The incidence of other AE was similar, although the overall AE rate was significantly higher after same session EUS-TA+ERCP (36% vs. 20%, p = 0.030).

CONCLUSION

Same session EUS-TA+ERCP did not significantly increase the incidence of PPP, although overall AE were significantly higher. These data warrant further prospective studies.

Efficacy of endoscopic samplings during initial biliary drainage for cases of pancreatic head cancer: United diagnostic yields of multiple pathological samplings

BACKGROUND/OBJECTIVES

The diagnostic ability of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been fully studied; however, the efficacy of other endoscopic samplings (OESs) is less clear. The aim of this study was to examine the diagnostic efficacies of OESs for pancreatic head cancer (PHC).

METHODS

The diagnostic efficacies of endoscopic samplings were retrospectively analyzed in 448 PHC cases and 63 cases of mass-forming pancreatitis (MFP) during initial transpapillary biliary drainage. The OESs included duodenal biopsy (118 PHCs and 50 MFPs), biliary biopsy (218 and 51) with cytology (368 and 53), and pancreatic duct biopsy (23 and 13) with cytology (56 and 43). EUS-FNA was conducted in a different session (149 and 62). Factors associated with OES sensitivity were analyzed. The sensitivity of biliary biopsy was compared between 1.95 mm and 1.8 mm forceps.

RESULTS

Cancer cells were confirmed in 87.9% of the EUS-FNA samplings and in 64.1% (268/418) obtained by combined OESs (average 1.7 OES types per case): 68.6% by duodenal biopsy, 59.6% by biliary biopsy, 32.6% by biliary cytology, 73.9% by pancreatic duct biopsy, and 33.9% by pancreatic duct cytology. No MFP cases revealed cancer by any sampling. OESs did not increase adverse events. Duodenal stenosis, serum bilirubin, tumor size, and pancreatic juice amounts were associated with OES sensitivity. Biliary biopsy had the same sensitivity with different forceps.

CONCLUSION

EUS-FNA was the most diagnostic protocol; however, OESs can be safely applied during the initial biliary drainage to reduce the demand for EUS-FNA while providing good diagnostic yields.

Impact of biliary stents on the diagnostic accuracy of EUS-guided fine-needle biopsy of solid pancreatic head lesions: A multicenter study

BACKGROUND AND OBJECTIVES

There is no clear evidence of a negative impact of biliary stents on the diagnostic yield of EUS-guided fine-needle biopsy (EUS-FNB) for diagnosing pancreatic head lesions. We aimed to evaluate the association between the presence of biliary stents and the diagnostic accuracy of EUS-FNB.

MATERIALS AND METHODS

A multicenter retrospective study including all jaundiced patients secondary to pancreatic head masses was performed. Patients were divided into two groups according to the presence of a biliary stent placed before EUS-FNB. Pathological results were classified according to the Papanicolaou classification and compared against the final diagnosis. Diagnostic measures in the two groups were compared. Multivariate logistic regression analyses including potential factors affecting EUS-FNB accuracy were performed.

RESULTS

Overall, 842 patients were included, 495 (58.8%) without and 347 (41.2%) with biliary stent. A plastic or a metal stent was placed in 217 (62.5%) and 130 (37.5%) cases, respectively. Diagnostic sensitivity and accuracy were significantly higher in patients without biliary stent than in those with stent (91.9% and 92.1% vs. 85.9% and 86.4%, P = 0.010 At multivariate analyses, lesion size (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.02-1.09, P = 0.01) and presence of biliary stent (OR: 0.51, 95% CI: 0.32-0.89, P = 0.01) were independently associated with diagnostic accuracy. In the subgroup of patients with biliary stent, the type of stent (plastic vs. metal) did not impact EUS-FNB yield, whereas the use of larger bore needles enhanced diagnostic accuracy (OR: 2.29, 95% CI: 1.28-4.12, P = 0.005).

CONCLUSIONS

In this large retrospective study, an indwelling biliary stent negatively impacted the diagnostic accuracy of EUS-FNB. Preferably, EUS-FNB should precede endoscopic retrograde cholangiopancreatography, especially in the case of small tumors.

Combined Versus Separate Sessions of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for the Diagnosis and Management of Pancreatic Ductal Adenocarcinoma with Biliary Obstruction

BACKGROUND

A single-procedure session combining EUS and ERCP (EUS/ERCP) for tissue diagnosis and biliary decompression for pancreatic duct adenocarcinoma (PDAC) is technically feasible. While EUS/ERCP may offer expedience and convenience over an approach of separate procedures sessions, the technical success and risk for complications of a combined approach is unclear.

AIMS

Compare the effectiveness and safety of EUS/ERCP versus separate session approaches for PDAC.

METHODS

Study patients (2010-2015) were identified within our ERCP database. Patients were analyzed in three groups based on approach: Group A: Single-session EUS-FNA and ERCP (EUS/ERCP), Group B: EUS-FNA followed by separate, subsequent ERCP (EUS then ERCP), and Group C: ERCP with/without separate EUS (ERCP ± EUS). Rates of technical success, number of procedures, complications, and time to initiation of PDAC therapies were compared between groups.

RESULTS

Two hundred patients met study criteria. EUS/ERCP approach (Group A) had a longer index procedure duration (median 66 min, p = 0.023). No differences were observed between Group A versus sequential procedure approaches (Groups B and C) for complications (p = 0.109) and success of EUS-FNA (p = 0.711) and ERCP (p = 0.109). Subgroup analysis (> 2 months of follow-up, not referred to hospice, n = 126) was performed. No differences were observed for stent failure (p = 0.307) or need for subsequent procedures (p = 0.220). EUS/ERCP (Group A) was associated with a shorter time to initiation of PDAC therapies (mean, 25.2 vs 42.7 days, p = 0.046).

CONCLUSIONS

EUS/ERCP approach has comparable rates of success and complications compared to separate, sequential approaches. An EUS/ERCP approach equates to shorter time interval to initiation of PDAC therapies.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Hindman NM, Arif-Tiwari H, Kamel IR, Al-Refaie WB, Bartel TB, Cash BD, Chernyak V, Goldstein A, Grajo JR, Horowitz JM, Kamaya A, McNamara MM, Porter KK, Srivastava PK, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Jaundice

Jaundice is the end result of myriad causes, which makes the role of imaging in this setting particularly challenging. In the United States, the most common causes of all types of jaundice fall into four categories including hepatitis, alcoholic liver disease, blockage of the common bile duct by a gallstone or tumor, and toxic reaction to a drug or medicinal herb. Clinically, differentiating between the various potential etiologies of jaundice requires a detailed history, targeted physical examination, and pertinent laboratory studies, the results of which allow the physician to categorize the type of jaundice into mechanical or nonmechanical causes. Imaging modalities used to evaluate the jaundiced patient (all etiologies) include abdominal ultrasound (US), CT, MR cholangiopancreatography, endoscopic retrograde cholangiopancreatography and endoscopic US. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

International consensus statements for endoscopic management of distal biliary stricture

Distal biliary strictures (DBS) are common and may be caused by both malignant and benign pathologies. While endoscopic procedures play a major role in their management, a comprehensive review of the subject is still lacking. Our consensus statements were formulated by a group of expert Asian pancreatico-biliary interventional endoscopists, following a proposal from the Digestive Endoscopy Society of Taiwan, the Thai Association for Gastrointestinal Endoscopy, and the Tokyo Conference of Asian Pancreato-biliary Interventional Endoscopy. Based on a literature review utilizing Medline, Cochrane library, and Embase databases, a total of 19 consensus statements on DBS were made on diagnosis, endoscopic drainage, benign biliary stricture, malignant biliary stricture, and management of recurrent biliary obstruction and other complications. Our consensus statements provide comprehensive guidance for the endoscopic management of DBS.

Safety and efficacy of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: A prospective multicenter study

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions has high diagnostic yield. However, few prospective multicenter studies have been performed. We performed a prospective cohort study to evaluate the efficacy and safety of EUS-FNA for diagnosis of solid pancreatic lesions.

METHODS

This prospective cohort study involved five hospitals in Japan. The primary outcome was sensitivity of EUS-FNA for diagnosing malignant lesions. We also evaluated parameters of diagnostic sufficiency and the safety of EUS-FNA.

RESULTS

In total, 246 patients were enrolled. The absolute values of the parameters evaluated showed no significant differences; however, the percentage changes in the white blood cell counts and C-reactive protein levels after examination were significantly higher, and the percentage change in hemoglobin concentrations was significantly lower. The minor and major complication rates at the time of puncture, 24 h, 7 days and 28 days were 4.1%, 2.8%, 1.6%, and 0.0%, respectively. The true complication rate was 1.2%. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97.2%, 88.0%, 96.2%, 100%, and 81.4%, respectively.

CONCLUSIONS

EUS-FNA for solid pancreatic lesions has high diagnostic yield and is safe, consistent with previously studies.

Comparison of the Diagnostic Performances of Same-session Endoscopic Ultrasound- and Endoscopic Retrograde Cholangiopancreatography-guided Tissue Sampling for Suspected Biliary Strictures at Different Primary Tumor Sites

Background/Aims

Determining the cause of suspected biliary stricture is often challenging in clinical practice. We aimed to compare the diagnostic yields of endoscopic ultrasound-guided tissue sampling (EUS-TS) and endoscopic retrograde cholangiopancreatography-guided tissue sampling (ERCP-TS) in patients with suspected biliary stricture at different primary lesions.

Methods

We enrolled patients who underwent same-session EUS- and ERCP-TS for the evaluation of suspected biliary stricture. Forceps biopsy and/or brush cytology of intraductal lesions and fine-needle aspiration for solid mass lesions were performed during ERCP and EUS, respectively.

Results

One hundred and twenty-five patients treated at our institution between January 2011 and September 2016, were initially considered for the study. However, 32 patients were excluded due to loss of follow-up (n=8) and ERCP-TS on the pancreatic duct (n=20) or periampullary lesions (n=4). Of the 93 patients included, 86 had a malignant tumor including cholangiocarcinoma (n=39), pancreatic cancer (n=37), and other malignancies (n=10). Seven patients had benign lesions. EUS-TS had higher rate of overall diagnostic accuracy than ERCP-TS (82.8% vs. 60.2%, p=0.001), and this was especially true for patients with a pancreatic lesion (84.4% vs. 51.1%, p=0.003).

Conclusions

EUS-TS was found to be superior to ERCP-TS for evaluating suspected biliary strictures, especially those caused by pancreatic lesions.

High-resolution endoscopic ultrasound imaging and the number of needle passages are significant factors predicting high yield of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid masses without an on-site cytopathologist

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the accurate diagnostic method for pancreatic masses and its accuracy is affected by various FNA methods and EUS equipment. Therefore, we aimed to elucidate the instrumental and methodologic factors for determining the diagnostic yield of EUS-FNA for pancreatic solid masses without an on-site cytopathology evaluation.We retrospectively reviewed the medical records of 260 patients (265 pancreatic solid masses) who underwent EUS-FNA. We compared historical conventional EUS groups with high-resolution imaging devices and finally analyzed various factors affecting EUS-FNA accuracy.In total, 265 pancreatic solid masses of 260 patients were included in this study. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of EUS-FNA for pancreatic solid masses without on-site cytopathology evaluation were 83.4%, 81.8%, 100.0%, 100.0%, and 34.3%, respectively. In comparison with conventional image group, high-resolution image group showed the increased accuracy, sensitivity and specificity of EUS-FNA (71.3% vs 92.7%, 68.9% vs 91.9%, and 100% vs 100%, respectively). On the multivariate analysis with various instrumental and methodologic factors, high-resolution imaging (P = 0.040, odds ratio = 3.28) and 3 or more needle passes (P = 0.039, odds ratio = 2.41) were important factors affecting diagnostic yield of pancreatic solid masses.High-resolution imaging and 3 or more passes were the most significant factors influencing diagnostic yield of EUS-FNA in patients with pancreatic solid masses without an on-site cytopathologist.

Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.

Biliary Brush Cytology Revisited

PURPOSE

To evaluate the diagnostic yield of biliary brush cytology and the factors affecting positive results in patients with biliary strictures.

PATIENTS AND METHODS

The medical records of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary brush cytology at our institution from November 2004 to December 2013 were reviewed in this retrospective study. The yield of positive brush cytology and the factors affecting positive yield, such as stricture location, age, gender and preprocedure CA 19.9 level were assessed. The final histopathology, diagnosis obtained by other methods, such as endoscopic ultrasound-guided fine-needle aspiration cytology, CT scan, Tru-Cut biopsy and/or clinical/radiological follow-up were used to identify true- and false-positive/negative results. The brush cytology results were divided into 4 main categories: malignant, benign, atypical cells and inadequate.

RESULTS

A total of 1,168 patients underwent ERCP during this 9-year period. Out of these, 142 patients had ERCP and biliary brushings for diagnosis. The mean age of the patients at presentation was 58.7 years (range 23-84 years; 64.8% males). The indication for referral was obstructive jaundice in all patients. Of the 142 patients, 77 (54.2%) had a distal common bile duct (CBD) stricture and 65 (45.8%) had a proximal /complex hilar stricture. The strictures were classified as proximal or distal, based on their relationship with the cystic duct; those below the cystic duct insertion were classified as distal and those above it were considered proximal. The diagnostic yield of brush cytology was 58.5%. The diagnostic yield was higher for proximal than for distal CBD strictures (67 vs. 50%; p = 0.047). It was also higher for females (58 vs. 57.6%; p = 0.94), patients >50 years (60 vs. 50%; p = 0.29) and those with a CA 19.9 level >300 IU/ml (59.4 vs. 55.5%; p = 0.65) but did not reach statistical significance for any of these parameters. Complete follow-up data were available for 96 patients and 46 patients were lost to follow-up. The sensitivity, specificity, positive predictive value and negative predictive value were 65.3, 100, 100 and 27%, respectively. When patients with atypia were included in the group with positive results, the diagnostic yield increased to 65.5% with a diagnostic sensitivity of 68.6%. There were 27 false-negative diagnoses, 10 patients were true-negative and no patients had a false-positive diagnosis.

CONCLUSION

Biliary brush cytology is a safe and simple initial diagnostic procedure in patients with biliary strictures and can be performed at the time of therapeutic ERCP. If performed correctly and then interpreted by a dedicated cytopathologist, it has a good diagnostic yield and sensitivity. We feel that the low rates of success with this technique reported in some earlier studies have led to a feeling that this is not a particularly useful technique. We recommend that this topic should be revisited, and that the technique should be used more often.

Yield of endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography for solid pancreatic neoplasms

OBJECTIVE

Both endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) cytology may provide tissue diagnoses in solid pancreatic neoplasms. However, there are scant data comparing these two methods. This study aims at retrospectively comparing EUS-FNA and ERCP tissue sampling and ability of cytopathological diagnosis in solid pancreatic neoplasms and to determine usefulness and adverse events of combining both procedures.

MATERIAL AND METHODS

Two hundred and thirty four patients suspected to have solid pancreatic mass on abdominal ultrasound and/or computed tomography (CT) were enrolled. EUS-FNA (group A), ERCP cytology (group B) and combined procedures (Group C) performed in 105, 91 and 38 cases, respectively.

RESULTS

Sensitivity, specificity and accuracy were 98.9%, 93.3% and 98.1% for group A, and 72.1%, 60% and 71.4% for group B. Those for group C were all 100%. Sensitivity for malignancy in the pancreas head was 100% for group A and 82.4% for group B, and in the pancreas body and tail, 97.6% for group A and 57.1% for group B. EUS-FNA was more sensitive than ERCP cytology in diagnosing malignant pancreatic neoplasms 21-30 mm in size (p = 0.0068), 31-40 mm (p = 0.028) and ≥ 41 mm (p < 0.0001). Sensitivity for pancreatic malignancy with group C was 100% regardless of mass location or size. Adverse events were 1.9%, 6.6% and 2.6% following EUS-FNA, ERCP and combined procedures, respectively.

CONCLUSIONS

EUS-FNA is superior to ERCP cytology for diagnosis of solid pancreatic neoplasms. Although combination of both procedures provide efficient tissue diagnosis and with a minimal adverse events rate, a prospective study including larger number of patients is required.

ERCP in potentially resectable malignant biliary obstruction is frequently unsuccessful when performed outside of a comprehensive pancreaticobiliary center

BACKGROUND AND OBJECTIVES

ERCP prior to pancreaticoduodenectomy is unnecessary in select patients. When performed, it should be in conjunction with endoscopic ultrasound (EUS) to increase diagnostic sensitivity and allow for metal stent placement. The aim of this study was to determine differences in endoscopic practice patterns at community medical centers (CMC) and a comprehensive pancreaticobiliary referral center (PBRC).

METHODS

Retrospective cohort study of all patients seen at a PBRC for endoscopic and/or surgical management of potentially resectable malignant distal biliary obstruction from 1/2011 to 6/2014.

RESULTS

Of 75 patients, 30 underwent endoscopic management at a CMC and 45 were initially managed at our PBRC. ERCP was attempted in 92% of patients. EUS was performed more frequently (100% vs. 13.3 %, P < 0.0001), ERCP was more successful (93% vs. 69%, P = 0.02), and metal stent placement more likely (41% vs. 5%, P = 0.005) at our PBRC compared to a CMC. The majority (81%) of patients undergoing initial endoscopy at a CMC required repeat endoscopy at our PBRC.

CONCLUSIONS

Patients who are candidates for pancreaticoduodenectomy frequently undergo ERCP. At a CMC, ERCP is often unsuccessful, is rarely accompanied by EUS, and often requires repeat endoscopy. Our findings support regionalizing the management of suspected pancreatic malignancy into dedicated specialty centers. J. Surg. Oncol. 2016;113:647-651. © 2016 Wiley Periodicals, Inc.

Performance characteristics of EUS for locoregional evaluation of ampullary lesions

BACKGROUND

The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear.

OBJECTIVES

To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012.

INTERVENTION

EUS.

MAIN OUTCOME MEASUREMENTS

Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy.

RESULTS

We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively.

LIMITATION

Retrospective design.

CONCLUSIONS

EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study

BACKGROUND

Both EUS and ERCP sampling techniques may provide tissue diagnoses in suspected malignant biliary obstruction. However, there are scant data comparing these 2 methods.

OBJECTIVE

To compare EUS-guided FNA (EUS-FNA) and ERCP tissue sampling for the diagnosis of malignant biliary obstruction.

DESIGN

Prospective, comparative, single-blind study.

SETTING

Tertiary center.

PATIENTS

Fifty-one patients undergoing same-session EUS and ERCP for the evaluation of malignant biliary obstruction over a 1-year period.

INTERVENTIONS

EUS-FNA and ERCP tissue sampling with biliary brush cytology and intraductal forceps biopsies.

MAIN OUTCOME MEASUREMENTS

Diagnostic sensitivity and accuracy of each sampling method compared with final diagnoses.

RESULTS

EUS-FNA was more sensitive and accurate than ERCP tissue sampling (P < .0001) in 51 patients with pancreatic cancers (n = 34), bile duct cancers (n = 14), and benign biliary strictures (n = 3). The overall sensitivity and accuracy were 94% and 94% for EUS-FNA, and 50% and 53% for ERCP sampling, respectively. EUS-FNA was superior to ERCP tissue sampling for pancreatic masses (sensitivity, 100% vs 38%; P < .0001) and seemed comparable for biliary masses (79% sensitivity for both) and indeterminate strictures (sensitivity, 80% vs 67%).

LIMITATIONS

Single-center study.

CONCLUSION

EUS-FNA is superior to ERCP tissue sampling in evaluating suspected malignant biliary obstruction, particularly for pancreatic masses. EUS-FNA appears similar to ERCP sampling for biliary tumors and indeterminate strictures. Given the superior performance characteristics of EUS-FNA and the higher incidence of pancreatic cancer compared with cholangiocarcinoma, EUS-FNA should be performed before ERCP in all patients with suspected malignant biliary obstruction. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01356030.).

Comparison of ERCP, EUS, and ERCP combined with EUS in diagnosing pancreatic neoplasms: a systematic review and meta-analysis

In the current study, we performed a systematic review of literature pertaining to the diagnostic value of endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), and combined ERCP plus EUS to pancreatic cancer. We searched MEDLINE, OVID, and the Cochrane Library for studies evaluating diagnostic validity of ERCP, EUS, and ERCP plus EUS between January 1989 and May 2014. We obtained pooled estimates of sensitivity, specificity, and summary receiver operating characteristic curves (SROC). A total of 10 studies that included 669 patients who fulfilled all of the inclusion criteria were considered for inclusion in the analysis. The pooled sensitivities of EUS, ERCP, and EUS plus ERCP were 76.7, 57.9, and 79.9 %, respectively. The pooled specificities were 91.7, 90.6, and 94.2 %, respectively. The *Q index estimates were 0.828, 0.862, and 0.896, respectively. The *Q indices for EUS and EUS plus ERCP were significantly higher compared with ERCP (P = 0.010 and 0.008, respectively). Our meta-analysis showed that ERCP plus EUS was associated with a high diagnostic value for the detection of pancreatic neoplasms compared with ERCP and EUS alone.

Safety and utility of single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for the evaluation of pancreatobiliary diseases

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are essential for diagnosing and treating pancreatobiliary diseases. Single-session EUS and ERCP are considered to be essential in reducing the duration of hospital stays; however, complications are a primary concern. The aim of this study was to evaluate the safety and efficacy of single-session EUS and ERCP. Sixty-eight patients underwent single-session EUS and ERCP at a tertiary referral center between June 2008 and December 2012. We retrospectively reviewed patient data from a prospectively maintained EUS-ERCP database and evaluated the procedural characteristics and complications. Thirty-eight patients (56%) underwent diagnostic EUS, and 30 patients (44%) underwent EUS fine-needle aspiration, which had an overall accuracy of 100%. Sixty patients (89%) underwent therapeutic ERCP, whereas the remaining eight procedures were diagnostic. Thirteen patients underwent biliary stone extraction, and 48 underwent biliary drainage. The median total procedural time was 75 minutes. Complications were observed in seven patients (10%). Six complications were post-ERCP pancreatitis, which were resolved using conservative management. One patient developed Mallory-Weiss syndrome, which required endoscopic hemostasis. No sedation-related cardiopulmonary complications were observed. Single-session EUS and ERCP provided accurate diagnosis and effective management with a minimal complication rate.

Evaluation of endoscopic cytological diagnosis of unresectable pancreatic cancer prior to and after the introduction of endoscopic ultrasound-guided fine-needle aspiration

With the advances in the multidisciplinary treatment of pancreatic cancer (PC) over the last few years, it is crucial to obtain a histopathological diagnosis prior to treatment. Histopathological diagnosis for unresectable PC is currently performed with endoscopic retrograde cholangiopancreatography (ERCP) in combination with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We retrospectively assessed the results of these two methods and investigated diagnostic performance according to the location of the lesion and the complications. This study was conducted on a series of 263 consecutive cases of unresectable PC diagnosed with endoscopic cytology. Up to 2006, ERCP-guided cytology (group A) was performed as the first choice for the diagnosis of PC. EUS-FNA was introduced in 2007 and became the first choice thereafter (group B), except in cases with obstructive jaundice, in which ERCP-guided cytology during endoscopic biliary stenting (EBS) remains the first choice. There were statistically significant differences in the overall cancer-positive rate between groups A and B (60.4 vs. 75.3%, P=0.01). The cancer-positive rate in the pancreatic body and tail was significantly higher in group B (59.5 vs. 83.3%, P=0.005), whereas there were no significant differences regarding cancer of the pancreatic head. The complication rate was 4.95% in group A and 3.09% in group B (P=0.448). The endoscopic cytology cancer-positive rate in unresectable PC cases was increased as a result of the introduction of EUS-FNA. In conclusion, we recommend performing EUS-FNA in combination with ERCP-guided cytology in cases with a lesion in the pancreatic head that requires EBS.

Role of endoscopic retrograde pancreatography for early detection of pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is often found with distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. The aim of this study was to clarify whether endoscopic retrograde pancreatography (ERP) would be useful for the early detection of concomitant PDACs in patients with IPMNs.

METHODS

Medical records of 179 patients who were histologically confirmed to have IPMNs after resection between 1987 and 2011 were reviewed. The patients having concomitant PDACs were selected, and the diagnostic abilities to detect concomitant PDACs of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), and ERP were compared between early (stages 0-I according to Japanese General Rules for Pancreatic Cancer) and advanced (stages II-IV) PDACs.

RESULTS

A total of 23 PDACs developed synchronously or metachronously in 20 patients, and the prevalence of PDACs concomitant with IPMNs was 11.2 % (20/179). Sensitivities of CT (16 vs. 87 %), MRI (29 vs. 93 %), and EUS (29 vs. 92 %) in the early group were significantly lower than those in the advanced group (p < 0.01). On the other hand, the sensitivity of ERP in the early group was as high as that in the advanced group (86 vs. 82 %, respectively, p > 0.99). Among 7 early PDACs, 3 were diagnosed only by ERP.

CONCLUSIONS

ERP has an important role in the early diagnosis of distinct PDACs in patients with IPMNs. Further investigation is necessary to clarify the indication and the timing of ERP during management of IPMNs in term of early detection of concomitant PDACs.

Factors affecting the yield of endoscopic transpapillary bile duct biopsy for the diagnosis of pancreatic head cancer

BACKGROUND

Transpapillary biliary biopsy (TBB) is a simple endoscopic technique that can be performed during an initial biliary drainage session. This procedure has the potential to reduce the load of another tissue sampling in cases of pancreatic head cancer (PHC) with biliary stricture. The aim of this study is to identify factors associated with a positive outcome using TBB for PHC.

METHODS

In total, 130 cases that underwent TBB for investigation of distal biliary stricture were included [62 cases of PHC, 36 cases of distal biliary cancer (DBC), and 32 cases of benign biliary stricture (BBS)]. Factors affecting the diagnostic efficiency of TBB were determined using univariate and multivariate logistic analyses.

RESULTS

Cancer tissue was obtained in 31 cases (50%) of PHC and 33 cases (91.7%) of DBC. Multivariable analysis showed that ≧10 mg/dl of serum bilirubin level (odds ratio [OR]: 5.58; 95% confidence interval [CI]: 1.29-28.20; P = 0.021) and ≧3 tissue samplings (OR: 3.59; 95% CI: 1.02-14.27, P = 0.046) were independent factors affecting cancer-positive rate in cases of PHC. In >90% of resected cases of PHC, cancer involved the left side of the biliary mucosa and the range of cancer invasion (≧2/3 of circumference of biliary mucosa) was also a significant factor (P = 0.001).

CONCLUSIONS

PHC showing high level of serum bilirubin (>10 mg/dl) and high circumferential proportion of bile duct invasion (>2/3 judging from MDCT) is a good indication for biliary biopsy. Targeting the left-side wall and ≧3 tissue samplings will lead to the higher sensitivity.

Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience

BACKGROUND

Several studies have investigated the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic lesions, but they have included only limited patient populations. This study aimed to clarify the diagnostic accuracy of EUS-FNA in a large number of pancreatic lesions, and to describe the factors that influence it.

METHODS

From March 1997 to May 2010, 944 consecutive patients who had undergone EUS-FNA for pancreatic solid lesions were evaluated retrospectively. Factors affecting EUS-FNA accuracy were then analyzed.

RESULTS

A total of 996 solid pancreatic lesions were sampled by EUS-FNA. The overall sampling adequacy and diagnostic accuracy of these lesions were 99.3 % (989/996) and 91.8 % (918/996), respectively. The sensitivity and specificity for differentiating malignant from benign lesions were 91.5 % (793/867) and 97.7 % (126/129), respectively. The diagnostic performance was significantly higher when both cytological and cell-block examinations were carried out than with only cytological examination. In multivariate analysis, final diagnosis, location of lesion, lesion size, availability of on-site cytopathological evaluation, and experience of EUS-FNA procedure were independent factors affecting the accuracy of EUS-FNA. On-site cytopathological evaluation and lesion size were found to be the most weighted factors affecting diagnostic accuracy.

CONCLUSIONS

EUS-FNA for pancreatic solid lesions yielded a high accuracy and low complication rate. Both cytological and cell-block preparations and on-site cytopathological evaluation contributed to improve the accuracy. The diagnostic ability of EUS-FNA was less for smaller lesions, and repeated procedures may be needed if malignancy is suspected.

Single-session endosonography and endoscopic retrograde cholangiopancreatography for biliopancreatic diseases is feasible, effective and cost beneficial

BACKGROUND

Endoscopic ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are often required in patients with pancreaticobiliary disorders.

AIMS

To assess the clinical impact and costs savings of a single session EUS-ERCP.

METHODS

Patient and intervention data from April 2009 to March 2012 were prospectively recruited and retrospectively analyzed from a database at a tertiary hospital. Indications, diagnostic yield, procedure details, complications and costs were evaluated.

RESULTS

Fifty-five scheduled combined procedures were done in 53 patients. The accuracy of EUS-fine needle aspiration for malignancy was 90%. The main clinical indication was a malignant obstructing lesion (66%). The ERCP cannulation was successful in 67%, and in 11/15 failed ERCP (73%), drainage was completed thanks to an EUS-guided biliary drainage: 6 transmurals, 5 rendezvous. Eight patients (14%) had related complications: bacteremia (n = 3), pancreatitis (n = 2), bleeding (n = 2) and perforation (n = 1). The mean duration was 65 ± 22.2 min. The mean estimated cost for a single session was €3437, and €4095 for two separate sessions. The estimated cost savings using a single-session strategy was €658 per patient, representing a total savings of €36,189.

CONCLUSION

Combined EUS and ERCP is safe, technically feasible and cost beneficial. Furthermore, in failed ERCP cases, the endoscopic biliary drainage can be completed with EUS-guided biliary access in the same procedure.

Endoscopic ultrasonography in tandem with endoscopic retrograde cholangiopancreatography in the management of suspected distal obstructive jaundice

GOALS

To examine the benefits and feasibility of endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in tandem for distal obstructive jaundice.

MATERIALS AND METHODS

From September 2007 to August 2012, patients with suspected distal obstructive jaundice were randomized to single-session EUS-ERCP (group A), EUS, and ERCP in different sessions (group B), and an ERCP-only procedure (group C). Data were prospectively collected on the following parameters: ERCP-avoided, duration of procedure, the dose of propofol, complications, and diagnostic yield.

RESULTS

A total of 180 patients were divided randomly into 60 patients in group A, 60 in group B, and 60 in group C. A total of four therapeutic ERCP were canceled after EUS. The ERCP procedural time in group A was shorter, although not significantly different from that in group B (group A vs. group B: 41.24±7.57 vs. 43.38±6.57 min; P>0.05), but both were significantly less than that in group C (group C: 49.12±7.46 min; P<0.05). The total procedural time did not differ significantly between group A and group B (70.05±15.35 vs. 73.70±15.12 min; P>0.05), nor were there significant differences in the dose of propofol between them (group A vs. group B: 357.11±115.86 vs. 369.55±133.86 mg; P>0.05). In all, 22 anesthetic complications and 21 endoscopic complications occurred without significant differences among the three groups (P>0.05).

CONCLUSION

As a triaging or a screening tool, diagnostic EUS gives added benefit to therapeutic ERCP. EUS and ERCP in a tandem approach are safe and feasible in patients with suspected distal obstructive jaundice.

Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer: a meta-analysis

BACKGROUND AND OBJECTIVE

EUS-FNA of pancreatic lesion has been put into clinical use widely in many centers. The present meta-analysis was conducted to study the diagnostic role of EUS-FNA in pancreatic cancer.

METHODS

A comprehensive review of study on the precision of EUS-FNA in the diagnosis of pancreatic cancer. A random effects model was used to pool the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR). A summary receiver-operating characteristic (SROC) was constructed to summarize the overall test performance.

RESULTS

Thirty-one articles were eligible for the meta-analysis. The pooled sensitivity, specificity, PLR, NLR and DOR of EUS-FNA in the diagnosis of pancreatic cancer were 0.89 (95% CI: 0.88-0.90), 0.96 (95% CI: 0.95-0.97), 16.88 (95% CI: 10.63-26.79), 0.13 (95%CI: 0.10-0.16) and 150.80 (95%CI: 95.94-237.03) respectively. In subgroup meta-analysis of the prospective studies, the pooled sensitivity, specificity, PLR, NLR and DOR were 0.91 (95% CI: 0.90-0.93), 0.94 (95% CI: 0.91-0.96), 11.19 (95% CI: 6.36-19.69), 0.10 (95% CI: 0.07-0.15) and 125.22 (62.37-251.41). The area under the curve (AUC) was 0.97, indicating a good performance of overall accuracy.

CONCLUSION

EUS-FNA has the high sensitivity and specificity in differentiating pancreatic cancer. Moreover, it is also a safe diagnostic modality with little complications.

Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis

BACKGROUND

Common bile duct (CBD) stones are a potentially life-threatening medical condition. Patients with proven CBD stones should undergo stone extraction. The aim of this study was to evaluate whether performing endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic CBD stones in a single session reduces complications related to postponing treatment due to separate EUS and ERCP sessions, and to assess the safety in both options.

METHODS

A total of 151 patients with EUS-proven CBD stones, with subsequent ERCP, treated in our department between January 2005 and December 2011 were included. Complications related to the procedures or sedation and complications due to the CBD stones when EUS and ERCP were not performed in a single session were assessed and compared to complications when the two procedures were performed in one session.

RESULTS

In total, 149 patients of the 151 (98.7 %) had a successful ERCP. Four (5 %) patients in the separate-session group (B) had a major complication compared to none in the single-session group (A) (p > 0.05). Group B received 14 % more midazolam during ERCP than group A (p < 0.05). No sedation-related complications were noted in either group. Eleven of the 80 patients in group B (13.8 %) experienced complications while waiting for ERCP compared to none in group A (p = 0.001, OR = 2.17, CI = 1.06-4.

CONCLUSIONS

EUS and ERCP done in a single session proved to be safe, with no increase in sedation- or procedure-related complications. Postponing treatment for symptomatic CBD stones exposes the patient to biliary complications, especially cholangitis.

Endoscopic palliation of pancreatic cancer

Endoscopy has an increasingly important role in the palliation of patients with pancreatic ductal adenocarcinoma. Endoscopic biliary drainage is still requested in the majority of patients who present with obstructive jaundice, and the increased use of self-expandable metallic stents has reduced the incidence of premature stent occlusion. First-line use of metallic stents is expected to be utilized more frequently as neoadjuvant protocols are improved. The efficacy of endoscopy for palliating gastroduodenal obstruction has advanced with the development of through-the-scope, self-expandable gastroduodenal stents. There have been advances in pain management, with endoscopic ultrasound-guided celiac plexus neurolysis reducing opiate requirements and pain for patients with unresectable malignancy. Future applications of endoscopy in pancreatic cancer may include fine-needle injection of chemotherapeutic and other agents into the lesion itself. This review will summarize the evidence of endoscopy in the management of patients with pancreatic cancer.

One- and two-step self-expandable metal stent placement for distal malignant biliary obstruction: a propensity analysis

BACKGROUND

Although self-expandable metal stents (SEMS) are widely used for distal malignant biliary obstruction, one-step SEMS (direct placement without a prior plastic stent) and two-step SEMS (placement at second endoscopic retrograde cholangiopancreatography [ERCP] following plastic stent placement) have not been fully compared.

METHODS

In this multicenter retrospective study, patients were included who underwent first-time endoscopic SEMS placement between September 1994 and December 2010. We compared the one-step and two-step strategies using a propensity analysis.

RESULTS

In total, 370 patients were identified and one-step SEMS was performed in 59 patients. After adjustment using propensity scores, the median times to dysfunction were 116 and 219 days, respectively, for one-step and two-step SEMS (P = 0.058). Stent migration was more frequently observed in one-step SEMS as compared with two-step SEMS (25 vs. 11 %, P = 0.031). In one-step SEMS, the number of days of hospitalization associated with first-time SEMS placement was shorter compared with that in two-step SEMS (21 vs. 30 days, P = 0.001), and the total costs of SEMS-related interventions within 6 months were lower (6510 and 8100 USD, P = 0.004). The pathological diagnosis rates for pancreatic and biliary tract cancer at initial ERCP were 52 and 61 %. After failed diagnosis at initial ERCP, pathological diagnosis rates for pancreatic cancer were 32 versus 76 % (P = 0.005) by repeated ERCP versus endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA).

CONCLUSIONS

One-step SEMS was associated with increased stent migration, despite having potential cost-effectiveness. The additional yield of pathological diagnosis at repeated ERCP was low compared with that yielded by EUS-guided FNA.

Effectiveness of combined endoscopic ultrasound-guided fine-needle aspiration biopsy and stenting in patients with suspected pancreatic cancer

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) can be coupled with endoscopic retrograde cholangiopancreatography in the same setting when biliary and/or duodenal stenting are required.

AIMS

Our aim was to examine the effectiveness of EUS-FNA combined with stenting during the same session in patients with pancreatic cancer.

METHODS

Consecutive patients referred for EUS-FNA of a pancreatic mass with symptoms of biliary (±upper digestive) obstruction were included. Consecutive patients undergoing biliary and/or duodenal stenting without EUS-FNA during the same period were used as controls. Procedure-related complications were the primary outcome measure. Duration of the procedure, ability to achieve biliary/duodenal stenting, the yield of EUS-FNA, and clinical outcomes were evaluated.

RESULTS

A total of 122 patients underwent combined EUS-FNA and stenting and 68 underwent stenting alone (control group). In the combined group, histological proof of cancer was obtained in 88.52% at first EUS-FNA and 95.08% after a second EUS-FNA. Biliary stent placement was successful in 97.5 and 98% in the combined and the control groups, respectively. There was no statistical difference between the groups for length of stay after endoscopy and for procedure-related mortality and morbidity within 30 days. The median time from endoscopy to chemotherapy in the combined group was 12 days.

CONCLUSION

Combined EUS-FNA and biliary and/or duodenal stenting is feasible in almost all patients with suspected pancreatic cancer, with no additional hazard and a high histological yield.

Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.

Comparison of the influence of plastic and fully covered metal biliary stents on the accuracy of EUS-FNA for the diagnosis of pancreatic cancer

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.

Modern diagnostic approaches to cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is a very aggressive tumor with poor survival. Therefore, early diagnosis and surgical resection are of paramount importance. Its diagnosis is difficult because access to the tumor is not easy. Biopsy is possible only for intrahepatic cholangiocarcinoma, which accounts for 10% of cases. Routine brush cytology from endoscopic retrograde cholangiopancreatography (ERCP) has a high specificity of 100% but unfortunately a low sensitivity of 30%. In this review we briefly describe new diagnostic techniques applicable to ERCP brush cytology specimens and targeting the genetic background of the disease, in particular fluorescence in situ hybridization (FISH) and digital image analysis (DIA).

DATA SOURCES

The PubMed database up to 2011 was used for the retrieval of relevant articles. The search terms FISH, fluorescence in situ hybridization, DIA, digital image analysis and cholangiocarcinoma were used. Both original and review articles were used.

RESULTS

FISH identifies cells with chromosomal abnormalities, mainly numerical aberrations, using a mixture of fluorescence-labeled probes. FISH offers a higher sensitivity than routine cytology, retaining a high level of specificity. The DIA criterion for malignancy is demonstration of aneuploidy. This technique increases the sensitivity to 40%, but the specificity remains low. Preliminary data from application to other tumors suggest that combination of FISH and DIA may be of further benefit.

CONCLUSIONS

The new techniques offer a significantly enhanced diagnostic efficacy in the evaluation of ERCP brush specimens. Apart from contributing to a more timely diagnosis, their wider application to cholangiocarcinoma may also facilitate the genetic study of the disease and add to our understanding of oncogenesis at the molecular level, with the prospect of identifying targets for novel therapeutic interventions.

Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions

BACKGROUND

Few studies have evaluated the impact of biliary stents on EUS-guided FNA.

AIM

To compare diagnostic yield of EUS-FNA in patients with or without biliary stents.

DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

Patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years.

MAIN OUTCOME MEASURES

The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis.

RESULTS

Of 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1-3] vs 2 [IQR = 1-4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1-4] vs 2 [IQR = 1-4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001).

LIMITATIONS

Retrospective study.

CONCLUSIONS

The presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA.

Combined ERCP and EUS in one session is safe in elderly patients when compared to non-elderly patients: outcomes in 206 combined procedures

AIMS

Combined ERCP/EUS is becoming common. Combined procedures are frequently performed in elderly patients. We hypothesized that combined ERCP/EUS is equally safe in elderly patients when compared to non-elderly patients.

METHODS

This was a retrospective single-center study comparing outcomes in elderly and non-elderly patients undergoing combined ERCP/EUS.

RESULTS

A total of 206 patients were included. Mean age was 65 years (M:F 113:93); 99 were <65 years and 107 were >65. Indications included: jaundice (51%), abnormal imaging (17%), pancreatic tumor (11%), abdominal pain (5%), stent placement/change (5%), acute or chronic pancreatitis (5%), other (6%). Fine needle aspiration was performed in 134 (65%) procedures. Malignancy was identified in 142/206 (69%) patients. Mean Charlson Comorbidity Index (CCI) was 7.5 (range 0-22). Among patients <65 years old there were no immediate adverse events. Long-term adverse events in patients <65 (within 30 days) included cholangitis (1), increasing abdominal pain (4), post-ERCP pancreatitis (3), nausea/vomiting (1), increasing fatigue (1), and increasing jaundice (1). A subgroup analysis among geriatric patients (>65) was performed. Mean CCI was 8.2 (range 0-22). There was one immediate adverse event of non-sustained ventricular tachycardia in a 76-year old. Long-term adverse events included increasing fatigue (1), nausea/vomiting (2), increasing abdominal pain (2), urosepsis (1), fever (2) and dehydration (1). There were no statistically significant differences in outcomes in elderly compared to non-elderly patients. Elderly patients had higher CCI scores (p = 0.04).

CONCLUSION

Combined ERCP/EUS in one session is safe in the general population and elderly patients, with no more adverse events than in non-elderly patients.

Diagnostic value of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic masses: A meta-analysis

AIM: To establish the overall diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for solid pancreatic masses.

METHODS: We searched PubMed (1966/2011-10), Cochrane Library (from establishment to 2011-10), CNKI (1994/2011-10), CBM (1978/2011-10) and Wanfang (2000/2011-10) databases to find all diagnostic tests about EUS-FNA for solid pancreatic masses. After collecting studies according to inclusion criteria of diagnostic tests, data (study background, design information and diagnostic parameters) were extracted. QUADAS items were used to evaluate the qualities of the included studies. Meta-disc software was used to handle data of included studies and to examine heterogeneity. The effect-model was selected according to outcomes of heterogeneity. After all included studies were weighted and combined, sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and their 95%CI were calculated, and SROC curve was drawn.

RESULTS: A total of 280 potentially relevant studies were retrieved. According to eligibility criteria, 18 studies were included (all in English). The meta-analysis results are as follows: pooled sensitivity 0.90 (95%CI, 0.89-0.92), pooled specificity 0.95 (95%CI, 0.93-0.97), PLR 13.56 (95%CI, 8.31-22.15), NLR 0.12 (95%CI, 0.10-0.15), DOR 143.62 (95%CI, 93.98-219.46) and SROC AUC 0.9711 (Q* = 0.9215). Moreover, subgroup analysis was performed to identify the sources of heterogeneity according to the presence or absence of an on-site cytopathologist. The SROC AUC was 0.9757 (Q* = 0.9295) in the presence of an on-site cytopathologist. The DOR in the presence of an on-site cytopathologist was higher that in the absence of an on-site cytopathologist [173.37 (95%CI, 98.09-306.44) vs 113.64 (95%CI, 60.22-214.46)].

CONCLUSION: EUS-FNA has a high sensitivity and specificity in the diagnosis of solid pancreatic masses, especially in the presence of an on-site cytopathologist.

Combined brush cytology and stent placement in a single session for presumed malignant biliary stricture

BACKGROUND AND AIM

  Biliary stricture may be benign or malignant and causes obstructive jaundice. Brush cytology is a simple technique for diagnosing the cause of biliary stricture; however, its sensitivity has been reported to be low. A technique that comprises diagnosing the cause of stricture with a satisfactory sensitivity and relieving jaundice is required. This study was designed to evaluate the diagnostic performance of brush cytology and the feasibility of the subsequent stent placement in a single endoscopic retrograde cholangiopancreatography (ERCP) session performed for presumed malignant biliary strictures.

METHODS

  Data were collected by reviewing the medical records of 100 consecutive patients with suspected malignant biliary stricture who underwent brush cytology followed by stent placement at our center. Diagnostic performance of brush cytology, completion rate of the whole procedures comprising brush cytology and stent placement, and complications were evaluated.

RESULT

  Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of brush cytology were 83%, 100%, 100%, 33% and 84%, respectively. Biliary stent was successfully inserted for all patients (100%) subsequent to brush cytology in a single ERCP session. Eight patients (8%) had complications.

CONCLUSION

  Brush cytology was performed with much higher sensitivity of 83% than those of previous reports and the subsequent stent placement was successfully completed in all cases. For presumed malignant biliary stricture, brush cytology should be selected as an initial attempt because this technique is simple and enables subsequent stent placement in a single ERCP session.

Role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis of solid pancreatic masses

Since it was developed in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been widely used and has been adapted for gastrointestinal and perigastrointestinal lesions. A medical literature review to evaluate the role of EUS-FNA for diagnosis of solid pancreatic masses showed a 78-95% sensitivity, 75-100% specificity, 98-100% positive predictive value, 46-80% negative predictive value and a 78-95% accuracy. The reported complication rates of EUS-FNA for pancreatic solid masses were 0-2%, although the criteria for complications varied among the studies. Because of its high diagnostic yield and low complication rate, EUS-FNA is cost-effective and widely applicable for the diagnosis of solid pancreatic masses, and is the best initial and the preferred secondary method compared with other biopsy techniques, such as endoscopic retrograde cholangiopancreatography-guided biopsy, computed tomography/ultrasound-FNA and surgery. Although EUS-FNA is 'a nearly perfected procedure,' controversy remains, such as the most suitable diameter of the needle, the appropriate number of needle passes and the necessity of on-site cytopathological evaluation. Recently investigators reported that using molecular analysis of EUS-FNA samples can achieve a higher diagnostic efficacy. Further research is encouraged to optimize the EUS-FNA procedure to reach its maximum diagnostic yield for solid pancreatic masses.

The role of linear array EUS for diagnosis of pancreatic malignancies in the current situation

Over the last few decades, the role of endoscopic ultrasound (EUS) in the diagnosis of pancreatic malignancies has greatly increased by allowing earlier diagnosis and appropriate staging. The development of linear array EUS also allows fine needle aspiration (FNA) to be carried out under real-time EUS guidance and offers definitive diagnosis, which has fundamentally changed the diagnostic approach to pancreatic malignancies. Moreover, linear array EUS with the EUS-FNA technique has a therapeutic application that has expanded the role of this procedure in the management of pancreatic malignancies. This review will focus on the features of linear array EUS and discuss the current role of linear array EUS in the diagnosis of pancreatic malignancies.

Endoscopic and anesthetic feasibility of EUS and ERCP combined in a single session versus two different sessions

AIM: To discuss the feasibility of single session endoscopic ultrasonography (EUS) to discuss and endoscopic retrograde cholangiopancreatography (ERCP) execution.

METHODS: Retrospective endoscopic and anesthetic outcome comparison of performing both EUS and ERCP in a single endoscopic session (Group I) versus performing each procedure in two different sessions (Group II) was made. The following variables were evaluated: epidemiological variables, American Society of Anesthesiologists Physical Status Classification (ASA) level, procedural time, propofol dose, anesthetic complications, endoscopic complications and diagnostic yield, and therapeutic procedures on both groups. T-student, Chi-Square and Fisher test were used for comparison.

RESULTS: We included 39 patients in Group I (mean age: 69.85 ± 9.25; 27 men) and 46 in Group II (mean age: 67.46 ± 12.57; 25 men). Procedural time did not differ significantly between both groups (Group Ivs Group II: 93 ± 32.78 vs 98.98 ± 38.17; P >0.05) but the dose of propofol differed (Group I vs Group II: 322.28 ± 250.54 mg vs 516.96 ± 289.06 mg; P = 0.001). Three patients had normal findings on both explorations. Three anesthetic complications [O₂ desaturation (2), broncoaspiration (1)] and 9 endoscopic complications [pancreatitis (6), bleeding (1), perforation (1), cholangitis (1)] occurred without significant differences between both groups (P > 0.05). We did not find any significant difference regarding age, sex, ASA scale level, diagnostic yield or therapeutic maneuvers between both groups.

CONCLUSION: The performance of EUS and ERCP in a single session offers a similar diagnostic and therapeutic yield, does not entail a higher complication risk and requires a significantly smaller dose of propofol for sedation compared with performing each exploration in a different session.

The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma

OBJECTIVES

Our aim was to determine whether the presence of a biliary stent during endoscopic ultrasound fine-needle aspiration (EUS-FNA) affects diagnosis and complication rates.

METHODS

Retrospective analysis was performed of 268 patients with pancreatic head or neck adenocarcinoma who underwent EUS-FNA at our academic medical center between 2000 and 2009. Endoscopic ultrasound fine-needle aspiration and endoscopic retrograde cholangiopancreatography reports, cytology results, and physicians' notes were reviewed.

RESULTS

A total of 170 patients without stents, 87 patients with stents placed more than 1 day before EUS, and 11 patients with stents placed less than 1 day before EUS were identified. In patients without stents, the tissue diagnosis rate via EUS-FNA was 92.4% compared with a rate of 88.5% for those with stents placed more than 1 day before EUS-FNA (P=0.36). However, the patients with stents placed immediately before EUS-FNA were more likely to have indeterminate results from the EUS-FNA than the other patients were (P=0.008). Complication rates were the same among the groups.

CONCLUSIONS

Pre-EUS stenting of biliary obstruction due to pancreatic adenocarcinoma does not influence the rate of tissue diagnosis if performed more than 1 day before EUS-FNA. Lack of immediate EUS access should not preclude stent placement in appropriate patients with malignant biliary obstruction who will undergo EUS-FNA.