Establishing the optimal number of passes during EUS-FNB for diagnosis of pancreatic solid lesions: Prospective multicenter study

Background and study aims The optimal number of needle passes during endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is not yet established. We aimed to perform a per-pass analysis of the diagnostic accuracy of EUS-FNB of solid pancreatic lesions using a 22G Franseen needle. Patients and methods Consecutive patients with solid pancreatic lesions referred to 11 Italian centers were prospectively enrolled. Three needle passes were performed; specimens were collected after each pass and processed individually as standard histology following macroscopic on-site evaluation (MOSE) by the endoscopist. The primary endpoint was diagnostic accuracy of each sequential pass. Final diagnosis was established based on surgical pathology or a clinical course of at least 6 months. Secondary endpoints were specimen adequacy, MOSE reliability, factors impacting diagnostic accuracy, and procedure-related adverse events. Results A total of 504 samples from 168 patients were evaluated. Diagnostic accuracy was 90.5% (85.0%-94.1%) after one pass and 97.6% (94.1%-99.3%) after two passes ( P =0.01). Similarly, diagnostic sensitivity and sample adequacy were significantly higher adding the second needle pass (90.2%, 84.6%-94.3% vs 97.5%, 93.8%-99.3%, P =0.009 and 91.1%, 85.7%-94.9% vs 98.2%, 95.8%-99.3%, P =0.009, one pass vs two passes, respectively). Accuracy, sensitivity, and adequacy remained the same after the third pass. The concordance between MOSE and histological evaluation was 89.9%. The number of passes was the only factor associated with accuracy. One case of mild acute pancreatitis (0.6%) was managed conservatively. Conclusions At least two passes should be performed for the diagnosis of solid pancreatic lesions. MOSE is a reliable tool to predict the histological adequacy of specimens.

Mobile Health technology in pediatric esophagogastroduodenoscopy quality indicators assessment: results from a national program of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

Upper endoscopy procedures (UEP, esophagogastroduodenoscopy [EGDS] and retrograde endoscopic retrograde cholangiography [ERCP]) are an established standard of care in pediatric gastroenterology. The Pediatric endoscopy quality improvement network (PEnQuIN) recently published its pediatric-specific endoscopy quality guidelines. This study, initiated by the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP), aims to evaluate the adherence of Italian Pediatric Endoscopy Centers to these established quality standards.

METHODS

Conducted between April 2019 and March 2021, this nationwide study utilized a smartphone app-based approach. Data encompassing pediatric endoscopy facilities, patient profiles, endoscopy indications, 17 procedure-related PEnQuIN indicators, and a GHAA-9m patient satisfaction questionnaire were systematically collected.

RESULTS

A comprehensive analysis of 3582 procedures from 24 PECs revealed that 2654 (76%) were UEP. The majority of centers (75%) involved more than one operator, with 9 PEC incorporating adult endoscopists, responsible for 5% of UEPs. Overall, adherence to quality standards was good; however, areas of improvement include sub-optimal reporting of sedation details, adherence to disease-specific guidelines, and patient satisfaction questionnaire completeness (56%). The complication rate aligned with literature standards (1%), and patient satisfaction was generally high. A noteworthy observation was a 30% decrease monthly reporting rate and a shift in disease-specific patterns following the COVID-19 outbreak.

CONCLUSIONS

Pediatric UEP practices in Italy adhere well to established quality standards. Emphasizing the adoption of disease-specific guidelines is crucial for optimizing resources, enhancing diagnostic accuracy, and minimizing unnecessary procedures. Prioritizing patient satisfaction is important for immediate enhancements in practice as well as for future research endeavors.

Can single-use versus standard duodenoscope improve ergonomics in ERCP? A comparative, simulation-based pilot study

Background and study aims Musculoskeletal disorders (MSDs) and injuries (MSIs) are frequent in gastrointestinal endoscopy. The aim of this study was to assess potential ergonomic advantages of a lighter single-use duodenoscope compared with a standard reusable one for endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP). Methods Three experienced endoscopists performed an ergonomic, preclinical, comparative protocol-guided simulation study of a single-use and a standard reusable duodenoscope using an anatomic bench model. Surface EMG signals from left forearm and arm muscles were recorded. A commercial inertial sensor-based motion capture system was applied to record body posture as well. Results A significant lowering of root mean square amplitude and amplitude distribution of biceps brachii signal (ranging from 13% to 42%) was recorded in all the participants when using a single-use duodenoscope compared with a reusable one. An overall reduction of muscle activation amplitude and duration was also associated with the single-use duodenoscope for forearm muscles, with different behaviors among subjects. Participants spent most of the time in wrist extension (> 80%) and ulnar deviation (> 65%). A consistent pattern of functional range of motion employed for completing all procedures was observed. Conclusions Our study showed that a lighter scope has a promising effect in reducing upper arm muscle activity during ERCP with potential benefit on musculoskeletal health in the ERCP setting.

Familial pancreatic cancer

Pancreatic cancer (PC) carries a poor prognosis with an overall 5-year survival of less than 10%. Early diagnosis, though cumbersome, is essential to allow complete surgical resection. Therefore, primary and secondary prevention are critical to reduce the incidence and to potentially prevent mortality. Given a relatively low lifetime risk of developing PC, identification of high-risk individuals is crucial to allow identification of pre-malignant lesions and small, localized tumors. Although 85-90% of PC cases are sporadic, we could consider risk stratification for the 5-10% of patients with a family history and the 3-5% of cases due to inherited genetic syndromes. These high-risk populations should be considered for screening and surveillance of PC. MRI/MRCP and EUS are the preferred modalities, due to their high sensitivity in lesion detection. Surveillance should be personalized, considering genetics and family history, and assessment of risk factors that may increase cancer risk. Screening programs should be limited to tertiary referral center, with high-volumes and adequate facilities to manage these patients.

Micro-Biopsy Forceps in the Assessment of Peritoneal Carcinomatosis: A Possible New Indication?

Peritoneal carcinomatosis (PC) is defined as a metastatic involvement of the peritoneum by several other primary sites and it is characterized by a marked worsening of prognosis, with limited treatment opportunities. Subsequently, PC should be ruled out before any invasive treatment is administered. A new through-the-needle micro-biopsy forceps (MF) was recently introduced that permits micro-histology cores. In this case series, we evaluated the feasibility of MF in the assessment of PC to complete patient diagnostic work-ups. Five consecutive patients referred for endoscopic ultrasound staging were sampled using MF. Sampling was feasible in all patients with a technical success of 100%. No adverse events were reported in any cases. This technique was feasible and safe with a technical success rate of 100%. It permitted sampling of peritoneal irregularity, obtained high-quality tissue fragments in all cases, and enabled an additional assessment, i.e., immunohistochemical staining.

Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Redesign of a GI endoscopy unit during the COVID-19 emergency: A practical model

The pandemic diffusion of the SARS-CoV-2 infection throughout the world required measures to prevent and strategies to control the infection, as well as the reallocation of the hospital structures in order to take care of an increased number of infected patients. Endoscopy Units should be able to perform endoscopic procedures on COVID-19 infected as well as on noninfected patients. The aim of this manuscript is to propose a model for a fast reorganization of the endoscopy department environment in order to safely perform endoscopic procedures in this Pandemic COVID-19 scenario, according to the current advices given by the Scientific Societies.

Inverted "upside-down" esophageal fully-covered self-expanding metal stent is effective for temporary treatment of colorectal strictures: a pilot case series

Background and study aims  Placement of a fully-covered self-expanding metal stent (FC-SEMS) is a valid alternative for benign and malignant colorectal strictures treatment. Despite the reportedly high technical success rate, stenting is still challenging, due to high rates of adverse events. Migration still represents the main issue, although several anti-migration systems have been proposed. Patients and methods  Before insertion, esophageal Beta Niti-S FC-SEMSs were inverted and reloaded on the deployment device to invert the proximal and distal parts of the stent, with the largest end placed above the stricture to contrast peristaltic activity. The inverted "upside-down" Beta Niti-S FC-SEMS was placed in five consecutive patients: four pts with benign anastomotic stricture unresponsive to repeated balloon dilation and persisting for at least 10 weeks, and one with malignant rectal neoplasia. In five patients, six inverted FC-SEMSs were placed. Results  The modified FC-SEMS did not migrate in 5/6 cases (83 %). Stent migration occurred in the neoplastic case, induced by neoadjuvant chemotherapy. The "upside-down" esophageal Beta Niti-S FC-SEMS stayed in place for an average of 6 weeks, achieving resolution of stricture in all patients but one, who required an additional stent placement, due to incomplete stricture resolution after 6 weeks. Conclusion  The inverted esophageal Beta Niti-S FC-SEMSs proved to be effective in treating colorectal stricture in all cases, with no spontaneous migration or significant side effects, and achieved resolution of strictures where a traditional approach, recommended by guidelines, failed.

Initial experience with EUS-guided microbiopsy forceps in diagnosing pancreatic cystic lesions: A multicenter feasibility study (with video)

Background and Objectives

Cystic lesions of the pancreas represent a diagnostic dilemma. Recently, a through-the-needle microbiopsy forceps has become available, enabling procurement of EUS-guided histological specimens from the pancreatic cyst wall. The aim of this study was to evaluate the use of this novel instrument in a multicenter clinical setting.

Patients and Methods

Patients referred for EUS evaluation of pancreatic cysts and attempted EUS-guided microbiopsy was included retrospectively from six international tertiary centers. Patient's demographics, EUS findings, technical and clinical success, and histopathological results were recorded.

Results

: A total of 28 patients were identified. We report a technical success rate of 85.7% (n = 24). Biopsies were generally of good quality and contributed to the diagnosis in 20 patients (clinical success of 71.4%). Three adverse events were recorded (10.7%).

Conclusions

The use of the microbiopsy forceps is feasible with acceptable rates of technical and clinical success. Prospective studies are warranted to determine the diagnostic potential compared to the other modalities. However, the results from this preliminary study are promising.

Gastric and duodenal polyps in familial adenomatous polyposis patients: Conventional endoscopy vs virtual chromoendoscopy (fujinon intelligent color enhancement) in dysplasia evaluation

AIM

To test the fujinon intelligent color enhancement (FICE) in identifying dysplastic or adenomatous polyps in familial adenomatous polyposis (FAP) patients.

METHODS

Seventy-six consecutive FAP patients, already treated by colectomy and members of sixty-five families, were enrolled. A FICE system for the upper gastro-intestinal tract with an electronic endoscope system and a standard duodenoscope (for side-viewing examination) were used by two expert examiners. Endoscopic resection was performed with diathermic loop for polyps ≥ 6 mm and with forceps for polyps < 6 mm. Formalin-fixed biopsy specimens were analyzed by two expert gastrointestinal pathologists blinded to size, location and number of FAP-associated fundic gland polyps.

RESULTS

Sixty-nine (90.8%) patients had gastric polyps (34 only in the corpus-fundus, 7 only in the antrum and 28 in the whole stomach) and 52 (68.4%) in duodenum (7 in the bulb, 35 in second/third duodenal portion, 10 both in the bulb and the second portion of duodenum). In the stomach fundus after FICE evaluation, 10 more polyps were removed from 10 patients for suspicious features of dysplasia or adenomas, but they were classified as cystic fundic gland after histology. In the antrum FICE identified more polyps than traditional endoscopy, showing a better tendency to identify adenomas and displastic areas. In the duodenum FICE added a significant advantage in identifying adenomas in the bulb and identified more polyps in the II/III portion.

CONCLUSION

FICE significantly increases adenoma detection rate in FAP patients but does not change any Spigelman stage and thus does not modify patient’s prognosis and treatment strategies.

Update on Enteral Stents

OPINION STATEMENT

The recent advances in enteral stents design and composition introduced novel usage and indications, heading to a continuous addition of prostheses application in clinical practice. Since the first use to palliate malignant diseases, improving patient's quality of life, in the last decades we assisted to a large spread, often becoming a first choice treatment in GI disorders. Indeed, the clinical indication of gastrointestinal stents includes endoscopic treatment of fistula and leaks besides the well-established role of restoring lumen patency in benign and malignant conditions. Several different kind of stents have been developed, each one with its own characteristics and benefits, including self-expandable plastic and metal stents, available as uncovered, partially covered, and fully covered as well as biodegradable stents. Recently, new drug-eluting stents, working both as palliative treatment and as local chemotherapy, are under evaluation. This review aims to critically evaluate the most recently published literature about enteral stents and to address endoscopists' choice for a better patient management.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial

BACKGROUND

Target Controlled Infusion is a sophisticated tool for providing optimal sedation regimen avoiding under or oversedation in gastrointestinal endoscopy.

AIMS

To compare standard moderate sedation vs. non-anaesthesiologist-administered propofol sedation during gastrointestinal endoscopy.

METHODS

Randomized controlled trial of 70 consecutive colonoscopies and 70 consecutive esophagogastroduodenoscopies (EGD). Standard group (n=70), received fentanyl (1 μg/kg)+midazolam (0.03-0.04 mg/kg) or midazolam only; propofol group (n=70), received fentanyl (1 μg/kg)+propofol Target Controlled Infusion (1.2-1.6 μg/ml) or propofol Target Controlled Infusion only. Discharge time, endoscopist satisfaction and patient satisfaction were recorded in all endoscopies.

RESULTS

Colonoscopy: discharge time was significantly shorter in the propofol than the standard group (1.1 ± 0.3 vs. 5 ± 10.2 min, respectively; P=0.03). Endoscopist satisfaction was significantly higher (98.3 ± 11.4/100 vs. 87.2±12/100; P=0.001); patient satisfaction was significantly higher (95 ± 9.3/100 vs. 85.5 ± 14.4/100; P=0.002) in the propofol compared to the standard group. EGD: discharge time was not significantly different in the propofol and standard groups (1.1 ± 0.7 vs. 3.9 ± 9.2 min, respectively; P=0.146). Endoscopist satisfaction was significantly higher (92.7 ± 14.3/100 vs. 82.8 ± 21.2/100; P=0.03); patient satisfaction was significantly higher (93.8 ± 18.2/100 vs. 76.5 ± 25.2/100; P=0.003). In the propofol group 94.3% of patients vs. 71.4% of patients in standard group asked to receive the same sedation in the future (P=0.021).

CONCLUSION

Target Controlled Infusion is a promising method for non-anaesthesiologist-administered propofol sedation.

Improved detection of incident dysplasia by probe-based confocal laser endomicroscopy in a Barrett's esophagus surveillance program

BACKGROUND

Probe-based confocal laser endomicroscopy (pCLE) is a new technique allowing in vivo detection of neoplastic tissue using a standard endoscope.

AIMS

Our aim was to compare the incident dysplasia detection rate of biopsies obtained by high-definition white light endoscopy (HD-WLE) or by pCLE in a cohort of patients with Barrett's esophagus (BE) participating in a surveillance program.

METHODS

Fifty of 100 patients underwent pCLE in addition to HD-WLE. Four-quadrant biopsy specimens according to the Seattle biopsy protocol were obtained in all patients to ensure standard-of-care. Diagnosis of dysplasia/neoplasia was made by a blinded gastrointestinal pathologist.

RESULTS

Incident high-grade dysplasia (HGD) and low-grade dysplasia (LGD) were diagnosed in 3/100 and in 16/100 cases. In the HD-WLE group, areas suspicious for neoplasia were not observed and dysplasia was diagnosed in 5/50 (10%) patients (one with HGD). In the pCLE group, areas suspicious for neoplasia were observed by pCLE in 21/50 (42%) patients; dysplasia was confirmed in 14 cases (28%) (two with HGD). The dysplasia detection rate was significantly higher in the pCLE group than in the HD-WLE group (P = 0.04). The sensitivity, specificity, positive and negative predictive values of pCLE for dysplasia were 100, 83, 67, and 100%, respectively.

CONCLUSIONS

Incident dysplasia can be more frequently detected by pCLE than by HD-WLE in BE. The higher dysplasia detection rate provided by pCLE could improve the efficacy of BE surveillance programs.

Carcino Embryonic Antigen and long-term follow-up of mucinous pancreatic cysts including intraductal papillary mucinous neoplasm

BACKGROUND AND AIMS

The utility of Carcino Embryonic Antigen (CEA) in differentiating malignant from benign pancreatic cysts is controversial. We sought to examine the role of CEA in differentiating benign from malignant cysts and its utility in progression of cyst size in follow-up.

METHODS

Retrospective chart review of patients who underwent Endoscopic Ultrasound with Fine Needle Aspiration for mucinous cysts between 1998 and 2010. CEA was measured in benign and malignant mucinous cysts. Coefficient of determination (R(2)) was used to measure the association between change in cyst size and CEA. Mann-Whitney test was used to compare the median values of CEA.

RESULTS

143 patients (38.4% males) were included (mean age 68.9 ± 0.8 years). 105 patients had intra-cystic CEA measured. 63 patients underwent surgery while 80 patients were in the follow-up group. In the surgical group, median CEA value for benign and malignant mucinous neoplasms was 796 and 438 ng/ml, respectively (p=0.79). The median follow-up was 21 months. There was no correlation between CEA level and progression in cyst size in patients who had >6 months of follow-up, R(2)=0.0002. Malignant transformation was observed in 5 (5.9%) patients.

CONCLUSION

CEA level was not predictive of malignant cyst nor cyst size progression over follow-up.

Bowel preparation with polyethylene glycol electrolyte solution: optimizing the splitting regimen

AIM

Quality of bowel cleansing significantly increases the shorter the time between bowel solution intake and endoscopic examination. We tested the efficacy and patient tolerability following a modified polyethylene glycol electrolyte (PEG) splitting regimen.

METHODS

This was a prospective, single-blind, randomized, study. Patients were assigned to receive either PEG 4 L the afternoon before colonoscopy or PEG 3 L the day before and 1 L 3h before the procedure the day of colonoscopy.

RESULTS

The study population consisted of 336 patients, including 168 participants in each study arm. Although the bowel preparation quality was similarly quoted as excellent/good following the split and full regimen (95.2% vs 92.8%; p=0.3), a significant (p<0.0001) shift from good towards an excellent preparation (26.8% vs 68.4%) was observed following the split regimen as compared to the full regimen (55.4% vs 37.5%). The incidence of side-effects did not differ. When patients were asked about a future preparation if needed, 69% and 31% following the split and full regimen, respectively, declared to accept again the same preparation, the difference being statistically significant (p<0.001).

CONCLUSIONS

Our data found that an excellent bowel cleansing could be frequently achieved by simply modifying the split regimen from the standard PEG 2 plus 2 L to 3 plus 1 L.

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of single-balloon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.

Management of pancreatic neuroendocrine tumors

Neuroendocrine tumors are a heterogeneous group of rare tumors originating from neuroendocrine cells with secretory characteristics, and are primarily located in gastric, duodenal, pancreatic, and small and large bowel mucosa. Due to their extremely variable biologic and clinical behaviour, diagnosis is often delayed after a prolonged workup. Many advances have been made in recent years in the diagnosis, characterization, and treatment of neuroendocrine tumors. This review focuses on pancreatic neuroendocrine tumors, discussing the relatively new, multidisciplinary approach to their management. A Pubmed search was performed, limited to papers published within the last five years, using the key words NETs, pancreatic NETs, pancreatic tumors, diagnosis, imaging, nuclear imaging, endoscopy, endoscopic ultrasound, and biochemical markers.