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Alwassief A, Al-Busafi S, Abbas QL, Al Shamusi K, Paquin SC, Sahai AV. Endohepatology: The endoscopic armamentarium in the hand of the hepatologist. Saudi J Gastroenterol 2024; 30:4-13. [PMID: 37988109 PMCID: PMC10852142 DOI: 10.4103/sjg.sjg_214_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023] Open
Abstract
ABSTRACT Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.
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Affiliation(s)
- Ahmed Alwassief
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Said Al-Busafi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Qasim L. Abbas
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Khalid Al Shamusi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Sarto C. Paquin
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
| | - Anand V. Sahai
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
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Chen YI, Sahai A, Donatelli G, Lam E, Forbes N, Mosko J, Paquin SC, Donnellan F, Chatterjee A, Telford J, Miller C, Desilets E, Sandha G, Kenshil S, Mohamed R, May G, Gan I, Barkun J, Calo N, Nawawi A, Friedman G, Cohen A, Maniere T, Chaudhury P, Metrakos P, Zogopoulos G, Bessissow A, Khalil JA, Baffis V, Waschke K, Parent J, Soulellis C, Khashab M, Kunda R, Geraci O, Martel M, Schwartzman K, Fiore JF, Rahme E, Barkun A. Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial). Gastroenterology 2023; 165:1249-1261.e5. [PMID: 37549753 DOI: 10.1053/j.gastro.2023.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/21/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M). METHODS In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles. RESULTS From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted. CONCLUSIONS Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO. CLINICALTRIALS gov, Number: NCT03870386.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Anand Sahai
- Service de Gastroentérologie, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Paris, France
| | - Eric Lam
- Division of Gastroenterology and Hepatology, St-Paul Hospital, Vancouver, British Columbia, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Mosko
- Division of Gastroenterology, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sarto C Paquin
- Service de Gastroentérologie, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Fergal Donnellan
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Avijit Chatterjee
- Division of Gastroenterology and Hepatology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jennifer Telford
- Division of Gastroenterology and Hepatology, St-Paul Hospital, Vancouver, British Columbia, Canada
| | - Corey Miller
- Division of Gastroenterology and Hepatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Etienne Desilets
- Division of Gastroenterology, Hôpital Charles-Le Moyne, Longeuil, Quebec, Canada
| | - Gurpal Sandha
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sana Kenshil
- Division of Gastroenterology and Hepatology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Gary May
- Division of Gastroenterology, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian Gan
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Natalia Calo
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Abrar Nawawi
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Gad Friedman
- Division of Gastroenterology and Hepatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Albert Cohen
- Division of Gastroenterology and Hepatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Thibaut Maniere
- Division of Gastroenterology, Hôpital Charles-Le Moyne, Longeuil, Quebec, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter Metrakos
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - George Zogopoulos
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ali Bessissow
- Department of Radiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jad Abou Khalil
- Division of Gastroenterology and Hepatology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Vicky Baffis
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kevin Waschke
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Josee Parent
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Constantine Soulellis
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology-Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Olivia Geraci
- Research Institute McGill University Health Centre, Montreal, Quebec, Canada
| | - Myriam Martel
- Research Institute McGill University Health Centre, Montreal, Quebec, Canada
| | - Kevin Schwartzman
- Respiratory Division, McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elham Rahme
- Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
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Willems P, Esmail E, Paquin SC, Deslandres E, Sahai AV. Rescue technique for long-term dysfunction of EUS-guided lumen-apposing metal stent cholodochoduodenostomy. Gastrointest Endosc 2023; 98:664-665. [PMID: 37379993 DOI: 10.1016/j.gie.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/26/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Philippe Willems
- Service de Gastroentérologie, Centre Hospitalier Universitaire de L'Université de Montréal; Centre de Recherche du Centre Hospitalier Universitaire de L'Université de Montréal, axe Cancer, Montréal, Canada
| | - Eslam Esmail
- Service de Gastroentérologie, Centre Hospitalier Universitaire de L'Université de Montréal, Montréal, Canada; Tropical Medicine Department, Tanta University, Tanta, Egypt
| | - Sarto C Paquin
- Service de Gastroentérologie, Centre Hospitalier Universitaire de L'Université de Montréal; Centre de Recherche du Centre Hospitalier Universitaire de L'Université de Montréal, axe Cancer, Montréal, Canada
| | - Erik Deslandres
- Service de Gastroentérologie, Centre Hospitalier Universitaire de L'Université de Montréal; Centre de Recherche du Centre Hospitalier Universitaire de L'Université de Montréal, axe Cancer, Montréal, Canada
| | - Anand V Sahai
- Service de Gastroentérologie, Centre Hospitalier Universitaire de L'Université de Montréal; Centre de Recherche du Centre Hospitalier Universitaire de L'Université de Montréal, axe Cancer, Montréal, Canada
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Esmail E, Paquin SC, Sahai AV. Protocol for a randomized controlled trial of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN) with vs without bupivacaine. Trials 2023; 24:576. [PMID: 37684697 PMCID: PMC10486028 DOI: 10.1186/s13063-023-07487-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a devastating disease with less than 5% 5-year survival. Inoperable patients often present with pain. Randomized controlled trial have shown that endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) improves pain control. It is usually performed by injecting bupivacaine followed by absolute alcohol around the celiac axis. STUDY DESIGN Single center, randomized, double blind controlled trial of EUS-CPN with and without bupivacaine in patients with inoperable malignancy (pancreatic or other) involving the celiac plexus. The study was approved by research ethics board with approval number of 2022-9969, 21.151 and registered on ClinicalTrials.gov (NCT04951804). DISCUSSION We hypothesize that bupivacaine is superfluous and may actually reduce pain control by diluting the neurolytic effect of alcohol. Bupivacaine is also potentially dangerous in that it may produce serious adverse events such as arrythmias and cardiac arrest if inadvertently injected intravascularly. CONCLUSION This randomized trial is designed to assess whether bupivacaine is of any value during EUS-CPN.
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Affiliation(s)
- Eslam Esmail
- CHUM, Montreal, Canada
- Tropical Medicine Department, Tanta University, Tanta, Egypt
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Al Khaldi M, Ponomarev A, Richard C, Dagbert F, Sebajang H, Schwenter F, Wassef R, De Broux É, Ratelle R, Paquin SC, Sahai AV, Loungnarath R. Safety and clinical efficacy of EUS-guided pelvic abscess drainage. Endosc Ultrasound 2023; 12:326-333. [PMID: 37693116 PMCID: PMC10437202 DOI: 10.1097/eus.0000000000000020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objectives EUS is a potential alternative for the drainage of abscesses. The aim of this study was to determine if EUS-guided pelvic abscess drainage is technically feasible, safe, and a valid option for abscess resolution. Methods We conducted a retrospective review from 2002 to 2020 at a single quaternary institution. EUS-guided pelvic abscess drainage via the transrectal route was performed in all patients with or without drain/stent placement. Technical and clinical success of EUS-guided pelvic abscess drainage was analyzed. Descriptive analyses and Fisher exact test were performed. Results Sixty consecutive patients were included in the study (53.5% male; mean age, 53.8 ± 17.9 years). Pelvic abscesses occurred mainly postoperatively (33 cases; 60.0%) and from complicated diverticulitis (14 cases; 23.3%). Mean diameter was 6.5 ± 2.4 cm (80% unilocular). Drainage was performed with EUS-guided stent placement (double-pigtail plastic or lumen-apposing metal) in 74.5% of cases and with aspiration alone for the remainder. Technical success occurred in 58 cases (97%). Of those with long-term follow-up after EUS-guided pelvic abscess drainage (n = 55; 91.7%), complete abscess resolution occurred in 72.7% of all cases. Recurrence occurred in 8 cases (14.5%) and persisted in 7 patients (12.5%), 7 of which were successfully retreated with EUS-guided pelvic abscess drainage. Accounting for these successful reinterventions, the overall rate of abscess resolution was 85.5%. Abscess resolution rate improved with drain placement (83%). Accounting for 7 repeat EUS-guided pelvic abscess drainages, overall abscess resolution improved. Two deaths occurred (3.4%) because of sepsis from failed source control in patients who had previously failed medical, radiological, and surgical treatment. Conclusions EUS-guided pelvic abscess drainage is technically feasible, safe, and an effective alternative to radiological or open surgical drainage. It also offers favorable clinical outcomes in different clinical situations.
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Affiliation(s)
- Maher Al Khaldi
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Alexander Ponomarev
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Carole Richard
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - François Dagbert
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Herawaty Sebajang
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Frank Schwenter
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Ramses Wassef
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Éric De Broux
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Richard Ratelle
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
| | - Sarto C. Paquin
- Department of Medicine, Division of Gastroenterology, CHUM, Montreal, QC, Canada
| | - Anand V. Sahai
- Department of Medicine, Division of Gastroenterology, CHUM, Montreal, QC, Canada
| | - Rasmy Loungnarath
- Digestive Surgery Service, Department of Surgery, Centre Hospitalier de l'Université de Montreal (CHUM), Montreal, QC, Canada
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Denault AY, Roberts M, Cios T, Malhotra A, Paquin SC, Tan S, Cavayas YA, Desjardins G, Klick J. Transgastric Abdominal Ultrasonography in Anesthesia and Critical Care: Review and Proposed Approach. Anesth Analg 2021; 133:630-647. [PMID: 34086617 DOI: 10.1213/ane.0000000000005537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of transesophageal echocardiography (TEE) in the operating room and intensive care unit can provide invaluable information on cardiac as well as abdominal organ structures and function. This approach may be particularly useful when the transabdominal ultrasound examination is not possible during intraoperative procedures or for anatomical reasons. This review explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine. We describe several reported applications using 10 views that can be used in the diagnosis of relevant abdominal conditions associated with organ dysfunction and hemodynamic instability in the operating room and the intensive care unit.
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Affiliation(s)
- André Y Denault
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Milton S. Hershey Penn State Medical Center, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Theodore Cios
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Milton S. Hershey Penn State Medical Center, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Anita Malhotra
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Sarto C Paquin
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal (CHUM)
| | - Stéphanie Tan
- Department of Radiology, Montreal Heart Institute, Université de Montréal
| | - Yiorgos Alexandros Cavayas
- Department of Medicine and Intensive Care Unit, Montreal Sacré-Coeur Hospital and Department of Medicine and Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - John Klick
- Department of Anesthesiology, University of Vermont Medical Center, Larner College of Medicine, University of Vermont, Burlington, Vermont
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Hassan GM, Wyse JM, Paquin SC, Gariepy G, Albadine R, Mâsse B, Trottier H, Sahai AV. A randomized noninferiority trial comparing the diagnostic yield of the 25G ProCore needle to the standard 25G needle in suspicious pancreatic lesions. Endosc Ultrasound 2021; 10:57-61. [PMID: 33402551 PMCID: PMC7980691 DOI: 10.4103/eus.eus_69_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Objectives The aim of the study was to perform the first randomized trial comparing the diagnostic yield, bloodiness, and cellularity of the 25G standard needle (25S) and the 25G ProCore™ needle (25P). Materials and Methods All patients referred to the tertiary care referral center for EUS guided fine-needle aspiration (EUS-FNA) of suspicious solid pancreatic lesions were eligible. EUS-FNA was performed in each lesion with both 25S and 25P needles (the choice of the first needle was randomized), using a multipass sampling pattern, without stylet or suction. Rapid on-site evaluation was used when possible. Pap-stained slides were read by a single experienced cytopathologist, blinded to the needle type. Results One hundred and forty-three patients were recruited. Samples were positive for cancer in 122/143 (85.3%) with the 25S needle versus 126/143 (88.1%) with the 25P needle, negative in 17/143 (11.9%) with the 25S needle versus 13/143 (9.1%) with the 25P needle, and suspicious in 4/143 (2.8%) with each needle. There was no difference in any outcome based on the type of the first needle. No carryover effect was detected (P = 0.214; NS). Cumulative logistic regression analyses showed no associations between the type of needle and diagnostic yield for cancer, cellularity, or bloodiness. The difference in the yield for cancer was 2.9% (-4.2; 10.1%); with the confidence interval upper within the predetermined noninferiority margin of 15%. Conclusion The 25S needle is noninferior to the 25P needle for diagnosing cancer in suspicious pancreatic lesions.
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Affiliation(s)
- Galab M Hassan
- Division of Gastroenterology, Department of Medicine, Réseau Hospitalier Neuchâtelois, Switzerland; Department of social and preventive Medicine, School of Public Health, Université de Montréal, Québec, Canada
| | - Jonathan M Wyse
- Division of Gastroenterology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Sarto C Paquin
- Division of Gastroenterology, Centre Hospitalier Universitaire de Montréal, Québec, Canada
| | - Gilles Gariepy
- Department of pathology, Centre Hospitalier Universitaire de Montréal, Québec, Canada
| | - Roula Albadine
- Department of pathology, Centre Hospitalier Universitaire de Montréal, Québec, Canada
| | - Benoît Mâsse
- Department of social and preventive Medicine, School of Public Health, Université de Montréal, Québec, Canada; Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Québec, Canada
| | - Helen Trottier
- Department of social and preventive Medicine, School of Public Health, Université de Montréal, Québec, Canada; Research Center, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Québec, Canada
| | - Anand V Sahai
- Division of Gastroenterology, Centre Hospitalier Universitaire de Montréal, Québec, Canada
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Chen YI, Callichurn K, Chatterjee A, Desilets E, Fergal D, Forbes N, Gan I, Kenshil S, Khashab MA, Kunda R, Lam E, May G, Mohamed R, Mosko J, Paquin SC, Sahai A, Sandha G, Teshima C, Barkun A, Barkun J, Bessissow A, Candido K, Martel M, Miller C, Waschke K, Zogopoulos G, Wong C. ELEMENT TRIAL: study protocol for a randomized controlled trial on endoscopic ultrasound-guided biliary drainage of first intent with a lumen-apposing metal stent vs. endoscopic retrograde cholangio-pancreatography in the management of malignant distal biliary obstruction. Trials 2019; 20:696. [PMID: 31818329 PMCID: PMC6902519 DOI: 10.1186/s13063-019-3918-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 11/18/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND & AIMS Endoscopic ultrasound guided-biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP); however, its growth has been limited by a lack of multicenter randomized controlled trials (RCT) and dedicated devices. A dedicated EUS-BD lumen- apposing metal stent (LAMS) has recently been developed with the potential to greatly facilitate the technique and safety of the procedure. We aim to compare a first intent approach with EUS-guided choledochoduodenostomy with a dedicated biliary LAMS vs. standard ERCP in the management of malignant distal biliary obstruction. METHODS The ELEMENT trial is a multicenter single-blinded RCT involving 130 patients in nine Canadian centers. Patients with unresectable, locally advanced, or borderline resectable malignant distal biliary obstruction meeting the inclusion and exclusion criteria will be randomized to EUS-choledochoduodenostomy using a LAMS or ERCP with traditional metal stent insertion in a 1:1 proportion in blocks of four. Patients with hilar obstruction, resectable cancer, or benign disease are excluded. The primary endpoint is the rate of stent dysfunction needing re-intervention. Secondary outcomes include technical and clinical success, interruptions in chemotherapy, rate of surgical resection, time to stent dysfunction, and adverse events. DISCUSSION The ELEMENT trial is designed to assess whether EUS-guided choledochoduodenostomy using a dedicated LAMS is superior to conventional ERCP as a first-line endoscopic drainage approach in malignant distal biliary obstruction, which is an important and timely question that has not been addressed using an RCT study design. TRIAL REGISTRATION Registry name: ClinicalTrials.gov. Registration number: NCT03870386. Date of registration: 03/12/2019.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada.
| | - Kashi Callichurn
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Avijit Chatterjee
- Division of Gastroenterology and Hepatology, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Etienne Desilets
- Division of Gastroenterology, Hôpital Charles-Le Moyne, University of Sherbrooke, Greenfield Park, QC, Canada
| | - Donnellan Fergal
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Ian Gan
- Division of Gastroenterology and Hepatology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sana Kenshil
- Division of Gastroenterology and Hepatology, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eric Lam
- Division of Gastroenterology and Hepatology, St-Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gary May
- Division of Gastroenterology and Hepatology, St-Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Jeff Mosko
- Division of Gastroenterology and Hepatology, St-Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sarto C Paquin
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Anand Sahai
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Gurpal Sandha
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada
| | - Christopher Teshima
- Division of Gastroenterology and Hepatology, St-Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Jeffrey Barkun
- Department of Surgery, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Ali Bessissow
- Department of Radiology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Kristina Candido
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Myriam Martel
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Corey Miller
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Kevin Waschke
- Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - George Zogopoulos
- Department of Surgery, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Clarence Wong
- Division of Gastroenterology and Hepatology, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
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Kaspy MS, Hassan GM, Paquin SC, Sahai AV. An assessment of the yield of EUS in patients referred for dilated common bile duct and normal liver function tests. Endosc Ultrasound 2019; 8:318-320. [PMID: 31249161 PMCID: PMC6791102 DOI: 10.4103/eus.eus_21_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs). Materials and Methods: Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database. Results: Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034). Summary: In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis). Conclusion: EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.
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Affiliation(s)
- Matthew S Kaspy
- Department of Gastroenterology, University of Montreal Hospital Center, Montréal, Québec, Canada
| | - Galab M Hassan
- Department of Gastroenterology, University of Montreal Hospital Center, Montréal, Québec, Canada
| | - Sarto C Paquin
- Department of Gastroenterology, University of Montreal Hospital Center, Montréal, Québec, Canada
| | - Anand V Sahai
- Department of Gastroenterology, University of Montreal Hospital Center, Montréal, Québec, Canada
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Affiliation(s)
- Galab M Hassan
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Sarto C Paquin
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Anand V Sahai
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Québec, Canada
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Hassan GM, Paquin SC, Albadine R, Gariépy G, Soucy G, Nguyen BN, Sahai AV. Endoscopic ultrasound-guided FNA of pelvic lesions: A large single-center experience. Cancer Cytopathol 2016; 124:836-841. [PMID: 27448147 DOI: 10.1002/cncy.21756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/29/2016] [Accepted: 05/20/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pelvic endoscopic ultrasound-guided fine-needle aspiration (PEUS-FNA) of rectal or perirectal lesions is safe, minimally invasive, and well tolerated. It provides valuable information, which can greatly influence patient management. Herein, the authors present what to their knowledge is the largest series to date of PEUS-FNA. METHODS PEUS-FNA specimens were retrieved from the archives of the study institution from January 2001 to March 2015. Only patients with solid pelvic lesions were examined. The cytopathology findings, immunohistochemistry, corresponding histology, and clinical data were collected. For analysis of accuracy, atypical or suspicious results were classified as "negative." The sensitivity and specificity of PEUS-FNA were calculated in a subset of patients with available surgical pathology. RESULTS A total of 127 cases meeting the current study criteria were obtained from patients who underwent PEUS-FNA at the study institution between January 2001 and March 2015. The mean age of the patients was 60 years, and 53% were female. Pelvic lesions were comprised of 72% masses and 28% lymph nodes, with a mean mass diameter of 27.38 mm (range, 5-100 mm). PEUS-FNA was positive for malignancy in 45% of cases, atypical/suspicious in 4.7% of cases, and negative for malignancy in 50.3% of cases. Surgical pathology was available for 44 patients. PEUS-FNA demonstrated 89.3% sensitivity, 100% specificity, a diagnostic accuracy of 93.2%, a positive predictive value of 100%, and a negative predictive value of 84.2%. No complications were noted. CONCLUSIONS PEUS-FNA is safe and effective for the investigation of pelvic lesions. Cancer Cytopathol 2016;124:836-41. © 2016 American Cancer Society.
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Affiliation(s)
- Galab M Hassan
- Department of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Sarto C Paquin
- Department of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Roula Albadine
- Department of Pathology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Gilles Gariépy
- Department of Pathology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Geneviève Soucy
- Department of Pathology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Bich N Nguyen
- Department of Pathology, Montreal University Medical Center, Montreal, Quebec, Canada
| | - Anand V Sahai
- Department of Gastroenterology, Montreal University Medical Center, Montreal, Quebec, Canada
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12
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Affiliation(s)
- Galab M Hassan
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Anand V Sahai
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Sarto C Paquin
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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13
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Affiliation(s)
| | - Anand V Sahai
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
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Abstract
Like any other technique, fine needle aspiration (FNA) proficiency requires adequate experience. Although this technique is not difficult to master, formal training will allow endosonographers to achieve better results. The following article is derived in two parts: (1) To review current knowledge on endoscopic ultrasound (EUS)-FNA training, discuss the current recommendations on training guidelines, explore other training adjuncts and review the latest studies evaluating the validity of current recommendations; and (2) to provide some basic grounds on the EUS-FNA technique. EUS-FNA can be broken down into a series of steps. Proper execution of each step will make FNA easier and likely increase its diagnostic yield. Adequate positioning of the lesion in regards to the ultrasound probe is a key factor to obtain best results. The following will discuss useful tips in order to achieve maximal success rates.
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Affiliation(s)
- Sarto C Paquin
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, St-Luc Hospital, Quebec H2X 3J4, Canada
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15
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Gimeno-García AZ, Elwassief A, Paquin SC, Sahai AV. Endoscopic ultrasound-guided fine needle aspiration cytology and biopsy in the evaluation of lymphoma. Endosc Ultrasound 2014; 1:17-22. [PMID: 24949331 PMCID: PMC4062204 DOI: 10.7178/eus.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 02/17/2012] [Accepted: 03/18/2012] [Indexed: 12/19/2022] Open
Abstract
Accurate diagnosis and subtyping of lymphoma have important prognostic implications and are generally required for treatment planning. Histological assessment, immunophenotyping, and genetic studies are usually necessary. Endoscopic ultrasound guided-fine needle aspiration cytology (EUS-FNAC) is a minimally invasive technique widely used for the evaluation of deep-seated benign and malignant lesions. However, the value of cytological samples in lymphoma diagnosis is still a matter of debate. Endoscopic ultrasound guided-fine needle biopsy (EUS-FNAB) can provide tissue core samples that may help overcome the limitations of cytology. The aim of this review is to summarize the available literature regarding EUS-FNAC and EUS-FNAB for the diagnosis and subtyping of lymphoma. In addition, we discuss its usefulness in the management of primary extra-nodal lymphomas, as well as technical issues that may influence sample quality.
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Affiliation(s)
- Antonio Z Gimeno-García
- Gastroenterology Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
| | - Ahmed Elwassief
- Internal Medicine Department, Gastroenterology Unit, Alhossien Hospital, Alazhar University, Cairo, Egypt
| | - Sarto C Paquin
- Gastroenterology Department, Saint Luc Hospital, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Anand V Sahai
- Gastroenterology Department, Saint Luc Hospital, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Gimeno‐García AZ, Elwassief A, Paquin SC, Gariépy G, Sahai AV. Randomized controlled trial comparing stylet-free endoscopic ultrasound-guided fine-needle aspiration with 22-G and 25-G needles. Dig Endosc 2014; 26:467-73. [PMID: 24877242 DOI: 10.1111/den.12204] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Previous studies comparing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) results with different gauge needles have all been carried out with the stylet in place and show no clear advantage to the larger 22-G needle. Similar data for stylet-free EUS-FNA (SF-EUS-FNA) are unavailable. The aim of the present study was to determine whether diagnostic yield and specimen adequacy is superior with the 22-G needle as compared to the 25-G needle. METHODS All patients ≥ 18 years referred for solid-lesion EUS-FNA were eligible. Patients with suspected diagnosis of lymphoma, gastrointestinal stromal tumor, sarcoidosis, significant coagulopathy (international normalized ratio > 1.5 or platelets < 50000/mm(3)), use of clopidogrel within 7 days of EUS, and pregnancy were excluded. The two needles were compared regarding diagnostic yield, sample adequacy, bloodiness, ease of puncture, visibility, number of passes, failures, and complications. RESULTS One hundred and twenty consecutive patients were included and 126 lesions were sampled. Sensitivity, specificity, positive predictive value and negative predictive value for the 22-G SF-EUS-FNA were 83%, 100%, 100% and 56%, respectively, and for the 25-G SF-EUS-FNA were 88.8%, 100%, 100% and 76.5%, respectively (P=NS). There were no significant differences between the 22-G and the 25-G FNA needles in sample adequacy, bloodiness, ease of puncture, FNA failure, visibility, number of passes and complications; and no significant differences between either needle were found in relation to lesion site. CONCLUSION For SF-EUS-FNA, the larger 22-G needle offers no advantage over the smaller 25-G needle.
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Affiliation(s)
| | - Ahmed Elwassief
- Internal Medicine Department, Gastroenterology UnitAlhossien Hospital, Alazhar University Cairo Egypt
| | - Sarto C. Paquin
- Department of GastroenterologyCentre Hospitalier de l'Université de Montréal Montreal Canada
| | - Gilles Gariépy
- Department of PathologyCentre Hospitalier de l'Université de Montréal Montreal Canada
| | - Anand V. Sahai
- Department of GastroenterologyCentre Hospitalier de l'Université de Montréal Montreal Canada
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Abstract
This article addresses the technique of endoscopic ultrasound-guided fine-needle aspiration of solid lesions to obtain cytologic specimens. The technique can be broken down into a sequence of steps. The ultimate goal is to maximize the likelihood of obtaining adequate tissue for diagnostic purposes. This requires a technique that ensures that the needle can be moved inside the lesion, under ultrasound guidance, as widely as possible, as easily as possible, and safely. The other variables such as suction, needle type, and stylet use are of secondary importance.
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Affiliation(s)
- Sarto C Paquin
- Centre hospitalier de l'Université de Montréal, 1058 Rue Saint Denis, Montréal, Québec H9E 1A8, Canada
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18
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Gimeno-García AZ, Paquin SC, Gariépy G, Sosa AJ, Sahai AV. Comparison of endoscopic ultrasonography-guided fine-needle aspiration cytology results with and without the stylet in 3364 cases. Dig Endosc 2013; 25:303-7. [PMID: 23368962 DOI: 10.1111/j.1443-1661.2012.01374.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 07/24/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNA) is traditionally carried out with the stylet, as it is believed to prevent blockage or contamination of the needle by tissue coming from the gastrointestinal wall. However, this recommendation has not been demonstrated on an empirical basis. The aim of the present study was to compare the yield of EUS-FNA in a very large series of patients with (S+) and without (S-) the stylet. METHODS Until 2004, the stylet was used for EUS-FNA in our center. After that, the stylet was never used. The results of all EUS-FNA in solid lesions carried out by one endosonographer with the same needle type were compared before and after stylet use was stopped. RESULTS 3364 EUS-FNA procedures (in 3078 patients) in solid lesions were included (1483 S+ and 1881 S-). There was no significant difference between the S+ and S- results for any variable other than the number of passes required. The number of passes was significantly lower in the S- group when sampling lymph nodes, wall lesions and when carrying out biopsies through the gastric or rectal wall. However the statistical differences disappeared after controlling for malignancy, location and lesion size. CONCLUSION This very large comparative study showed no benefit in diagnostic yield when using the stylet for EUS-FNA.
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Affiliation(s)
- A Z Gimeno-García
- Gastroenterology Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
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20
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Wyse JM, Carone M, Paquin SC, Usatii M, Sahai AV. Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer. J Clin Oncol 2011; 29:3541-6. [PMID: 21844506 DOI: 10.1200/jco.2010.32.2750] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Celiac plexus neurolysis (CPN) is currently used as salvage therapy for morphine-resistant pancreatic cancer pain. Endoscopic ultrasound-guided CPN (EUS-CPN) can be performed early, at the time of EUS. We hypothesized that early EUS-CPN would reduce pain and morphine consumption, increase quality of life (QOL), and prolong survival. PATIENTS AND METHODS Patients were eligible if referred for EUS for suspected pancreatic cancer with related pain. If EUS and EUS-guided fine-needle aspiration cytology confirmed inoperable adenocarcinoma, patients were randomly assigned to early EUS-CPN or conventional pain management. Pain scores (7-point Likert scale), morphine equivalent consumption, and QOL scores (Digestive Disease Questionnaire-15) were assessed at 1 and 3 months. RESULTS Five hundred eighty eligible patients were seen between April 2006 and December 2008. Ninety-six patients were randomly assigned (48 patients per study arm). Pain relief was greater in the EUS-CPN group at 1 month and significantly greater at 3 months (difference in mean percent change in pain score = -28.9 [95% CI, -67.0 to 2.8], P = .09, and -60.7 [95% CI, -86.6 to -25.5], P = .01, respectively). Morphine consumption was similar in both groups at 1 month (difference in mean change in morphine consumption = -1.0 [95% CI, -47.7 to 49.2], P = .99), but tended toward lower consumption at 3 months in the neurolysis group (difference in mean change in morphine consumption = -49.5 [95% CI, -127.5 to 7.0], P = .10). There was no effect on QOL or survival. CONCLUSION Early EUS-CPN reduces pain and may moderate morphine consumption in patients with painful, inoperable pancreatic adenocarcinoma. EUS-CPN can be considered in all such patients at the time of diagnostic and staging EUS.
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Affiliation(s)
- Jonathan M Wyse
- MDCM, MSc, Centre Hospitalier de l'Universite de Montreal, Hopital Saint Luc, 1058 Rue Saint Denis, Montreal, Quebec H2X 3J4, Canada.
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21
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Sahai AV, Paquin SC, Gariépy G. A prospective comparison of endoscopic ultrasound-guided fine needle aspiration results obtained in the same lesion, with and without the needle stylet. Endoscopy 2010; 42:900-3. [PMID: 20725886 DOI: 10.1055/s-0030-1255676] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS The effectiveness of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with (S+) and without (S-) a stylet has never been compared. We prospectively compared the yield for malignancy and sample quality of S+ and S- EUS-FNA. PATIENTS AND METHODS S+ or S- EUS-FNA was performed on consecutive solid lesions, with a 22-gauge needle, with systematic assignment of S+ or S- passes in a 1 : 2 ratio. Slides were read by a single, blinded cytologist and were rated for bloodiness, adequacy, and presence of malignancy. The yield for malignancy was compared only in lesions in which equal numbers of S+ and S- passes were performed. RESULTS A total of 309 passes (mean 2.3 passes/lesion, range 1-6, 82% adequate, 38% S+, 62% S-) were performed on 135 lesions (63% malignant, 42% nodes, 58% masses [79% pancreatic]) in 111 patients (mean age 62.9 years, range 30-86). In 46 lesions where an equal number (53 S+ and 53 S-) of passes was performed, there was no difference in the proportion of cases in which S+ FNA was "equal to or better than" S- FNA ([S+] 89% vs. [S-] 87%; P>0.05). The results of the two methods agreed in 80% cases (kappa 0.60). The sensitivities for malignancy were: S+ 87% vs. S- 83%, P>0.05. Specificities were 100%. Sample adequacy was significantly lower in S+ passes (75% vs. 87%, P=0.013), and sample bloodiness was significantly higher (75% vs. 52%, P<0.0001). CONCLUSIONS Use of the stylet with EUS-FNA does not increase the yield for malignancy and is associated with poorer sample quality. The value of the stylet for EUS-FNA is questionable and requires further investigation.
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Affiliation(s)
- A V Sahai
- Department of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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Sahai AV, Lemelin V, Lam E, Paquin SC. Central vs. bilateral endoscopic ultrasound-guided celiac plexus block or neurolysis: a comparative study of short-term effectiveness. Am J Gastroenterol 2009; 104:326-9. [PMID: 19174816 DOI: 10.1038/ajg.2008.64] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS)-guided celiac plexus block/neurolysis (CPB/N) can be performed by injecting at the base (central) or on either side (bilateral) of the celiac axis. Central CPB/N is easier and possibly safer. Bilateral CPB/N is more difficult but may be more effective as it reaches more ganglia. The aim of this study was to compare the short-term safety and efficacy of central and bilateral CPB/N. METHODS Consecutive patients referred for CPB/N to a quaternary EUS center were eligible for this study. Central CPB/N was used in the first half of the study period and bilateral CPB/N in the last half. The primary outcome was the percent reduction in visual analog pain scores at day 7. RESULTS A total of 184 patients were eligible. Out of them, 24 (13%) were excluded for incomplete data. A total of 160 were left (71 central, 89 bilateral). The groups were similar for all cogent variables. Bilateral CPB/N was more effective than central CPB/N (mean percent pain reduction 70.4% (61.0-80.0) vs. 45.9% (32.7-57.4); P=0.0016). The only predictor of a >50% pain reduction was bilateral CPB/N (odds ratio 3.55, 1.72-7.34). Only one complication was noted: self-limited bleeding because of laceration of the adrenal artery following bilateral celiac plexus (CP) block in an anticoagulated patient. CONCLUSIONS (i) Bilateral CPB/N is more effective than central CPB/N; (ii) bilateral CPB/N is safe, but on rare occasions can cause trauma to the left adrenal artery; it should therefore be avoided in patients with a bleeding diathesis.
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Lam EC, Rego RR, Paquin SC, Chua TS, Raymond G, Sahai AV. In patients referred for investigation because computed tomography suggests thickened gastric folds, endoscopic ultrasound is superfluous if gastroscopy is normal. Am J Gastroenterol 2007; 102:1200-3. [PMID: 17319928 DOI: 10.1111/j.1572-0241.2007.01151.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Endoscopic ultrasound (EUS) is often requested in patients in whom computed tomography (CT) shows gastric wall thickening. It is unclear if EUS is useful if upper endoscopy is normal. The aim of this study was to prospectively compare the yield of upper endoscopy and EUS for this indication. METHODS All patients referred for endoscopic ultrasound because of thickened gastric folds on CT from May 2001 and June 2003 were included. A single physician, questioned, examined, and performed upper endoscopy followed by EUS in all patients. Data were recorded prospectively. The main outcome measures were: upper endoscopy and EUS findings and predictors of abnormal EUS. RESULTS Sixty-nine patients were enrolled. The average age was 57.9, 49% were male, 51% were asymptomatic, 57% had normal upper endoscopy, and 70% had normal EUS. If upper endoscopy was abnormal, EUS was abnormal in 70% of cases (95% CI 62%-78%). If upper endoscopy was normal, the EUS was normal in 100% of cases (95% CI 92%-100%). Multivariate analysis revealed that neither age, gender, presence of abdominal symptoms nor alarm symptoms predicted abnormal EUS. CONCLUSIONS When CT shows gastric wall thickening: (a) Nnormal upper endoscopy is strongly associated with normal EUS; (b) abnormal upper endoscopy is associated with abnormal EUS in 70% of cases; (c) clinical variables such as age, sex, and the presence of symptoms do not predict or increase the likelihood of abnormal EUS. Therefore, in patients with thickened gastric wall on CT, upper endoscopy should be used to select patients for EUS.
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Affiliation(s)
- Eric C Lam
- Department of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Affiliation(s)
- Sarto C Paquin
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l'Université de Montrial, Hôpital St-Luc, Montreal, Quebec, Canada
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Abstract
The hepatorenal syndrome (HRS) is related to vasoconstriction of the renal cortex induced by systemic hypovolemia that follows splanchnic vasodilatation as the primary event in the cascade of hemodynamic changes associated with portal hypertension. We evaluated the effects of octreotide, a splanchnic vasoconstrictor, on HRS in cirrhotic patients. We compared the effects of octreotide infusion (50 microg/h) to placebo using a randomized, double-blind, cross-over design over 2, 4-day periods. Nineteen patients were included, and 14 patients could complete the 2 phases of the study (group 1: placebo first; n = 8 and group 2: octreotide first; n = 6) The end point of the study was to evaluate improvement in renal function as defined by a 20% decrease in serum creatinine value after a 4-day treatment as compared with baseline. In all the patients, a normal central venous pressure was maintained by daily intravenous administration of 2 units of albumin. The 2 groups were similar with regard to demographic data and liver and kidney function parameters at baseline. Improvement in renal function was observed in 2 patients after the placebo and 1 patient after octreotide infusion in group 1 and in 2 patients after octreotide infusion and 1 patient after placebo in group 2 (P = not significant). In addition, treatment with octreotide infusion did not result in significant changes in creatinine clearance, daily urinary sodium, plasma renin activity, plasma aldosterone and glucagon levels, or renal and mesenteric artery resistance indices as measured by Doppler ultrasonography. In conclusion, the present study demonstrates that, under our experimental conditions, octreotide infusion combined with albumin is not effective for the treatment of HRS in cirrhotic patients.
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Affiliation(s)
- Gilles Pomier-Layrargues
- Liver Unit, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.
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