Introduction: Differentiating pancreatic cystic neoplasms remains a challenge using the current technique of Endoscopic Ultrasound-guided fine needle aspiration (EUS-FNA). Recently, a miniaturized biopsy forceps with an outer diameter of acquire tissue. This through-the-needle forceps biopsy technique (TTNFB) has the potential to increase the diagnostic yield of EUS-FNA for pancreatic cystic neoplasms. The primary aim of this study was to evaluate the technical success and safety of EUS-guided TTNFB for pancreatic cystic lesions. The secondary aim was to evaluate the additive value in diagnostic yield this technique may afford over standard EUS-FNA for pancreatic cystic lesions. Methods: This was a retrospective review of all cases of EUS-guided TTNFB performed for pancreatic cystic lesions at a single academic institution over a 12-month period. Technical success was defined as acquisition of adequate tissue for formal histologic analysis. Safety was assessed through recording peri/post procedural adverse events. EUS-TTN forceps biopsy was performed using the Moray® forceps (US Endoscopy, Mentor, OH) through a standard 19G FNA needle. Biopsy of the cyst wall or septum was performed in each case using the same technique. EUS-FNA of cyst fluid for analysis was performed on each patient when possible. When intraductal papillary mucinous neoplasms (IPMN) was suspected, mucin (MUC) staining was performed to verify the results of the histology and to subtype IPMN. Results: The study included 15 cystic lesions (mean size 26.6mm) in 15 patients. Technical success was 87% (13/15). There was 1 adverse event of intracystic bleeding with no clinical sequelae (6.7%). There were no episodes of pancreatitis. EUS-guided TTNFB with histologic analysis yielded a diagnosis in 11/15 patients (73%) as compared to 0/15 (0%) patients using EUS-FNA and cytologic analysis (p < 0.01). 7 of 8 IPMNs were able to be subtyped based on histologic analysis and MUC staining. Conclusion: This study demonstrates that EUS-TTN forceps biopsy of pancreatic cystic lesions appears safe and can be performed with high technical success. TTN forceps biopsy with histologic analysis demonstrated a significantly higher diagnostic yield for pancreatic cystic lesions compared to EUS-FNA and cytologic analysis. Furthermore, subtyping of IPMN was feasible in this study. EUS-guided through the needle forceps biopsy is a novel technique that should be considered in the diagnostic algorithm for patients with pancreatic cystic lesions.
Background and study aims Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). There has been concern about adverse events (AEs) with LAMS including bleeding, buried stent syndrome and migration. Prior to LAMS becoming available, fully-covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of PC/WON with many centers demonstrating low rates of AEs. The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON. Patients and methods This was a retrospective review of all endoscopic ultrasound (EUS)-guided placement of FCSEMSs for drainage of PC/WON cases performed at our institution over 4-year period. The primary outcomes studied were technical success, AEs, PC/WON resolution, and salvage surgical/radiologic intervention. Results Technical success achieved in 65 of 65 (100 %) study patients. An AE occurred 0 of 25 patients (0 %) with PC, and in 10 of 40 patients (25 %) with WON: bleeding (3 %), migration (5 %) and stent dysfunction/infection (18 %). There was resolution in 25 of 25 patients (100 %) with a PC and 31 of 40 patients (78 %) with a WON. Salvage therapy by interventional radiology or surgery was performed in nine of 40 patients (22 %). Conclusions This single-center 4-year experience in the pre-LAMS era showed that FCSEMS was safe and effective in all patients with PC and over 75 % of patients with WON. Given the large cost differential between LAMS and FCSEMS and the efficacy and safety shown with FCSEMS, we believe that FCSEMS should still be considered a first-line option for patients with pancreatic fluid collections, particularly in patients with PCs.
This is a 44-year-old male with a reported history of GERD symptoms who underwant Nissen Fundoplication in 2013 in South America. Some intermittent heartburn symptoms appeared to improve but post surgical dysphagia became a problem for him. In 2015, dysphagia symptoms progressed and started to lose weight. Bravo pH monitoring revealed acid reflux was well controlled. An EGD with Endoflip balloon manometry was performed, which was remarkable for a a narrow esophageal diameter and and poor GEJ compliance. Conservative management was pursued at first, given there was a possibility a tight fundoplication could relax. However, the symptoms persisted, and underlying Achalasia was suspected. Thus decision was made to use intraoperative EndoFLIP to help make the diagnosis. The previously performed Nissen Fundoplication was taken down and with no mechanical constriction on the GEJ, intraoperative EGD with repeat Endoflip balloon manometry was performed with measurements consistent with Achalasia (Diameter 6mm, Compliance 2.1mm/Hg2). As a result, a heller Myotomy with Dor Fundoplication was then completed. The patient had a drastic improvement in symptoms and continues to do well 1 year after this procedure. This study highlights the importance of a thorough pre-operative work up prior to Nissen Fundoplication. This patient had a minimal pre-fundoplication workup performed and the patients original symptoms in retrospect may not have been all GERD related. Evaluating a patient who presents with dysphagia after fundoplication is a difficult task. It is difficult to discern if the dysphagia is due to a tight fundoplication or an underlying condition such as Achalasia. This is the first case to our knowledge that used EndoFLIP balloon manometry intraoperatively after a fundoplication was taken down to make a diagnosis of Achalasia such that the appropriate therapy could be carried out on the same day.
INTRODUCTION: Multiple computer-aided techniques utilizing artificial intelligence have been created to improve the detection of polyps during colonoscopy and thereby reduce the incidence of colorectal cancer. The purpose of this systematic review and meta-analysis was to determine the efficacy of computer-aided colonoscopy (CAC) with respect to adenoma and polyp detection rates. METHODS: A comprehensive, systematic literature search was performed across multiple databases in May of 2020 to identify randomized, controlled trials that compared CAC to traditional colonoscopy. Primary outcomes were adenoma detection rate (ADR) and polyp detection rate (PDR). Secondary outcomes included size, morphology, and location of detected adenomas. RESULTS: 6 studies totaling 5058 patients were included. There was a 76% increase in ADR (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.55–2.00, P < 0.001, I2 = 28%) and an 86% increase in PDR (OR, 1.86; 95% CI, 1.66–2.09, P < 0.001, I2 = 0%) in the CAC group compared to the control group. There was a 108% increase in the number of 0–5 mm adenomas detected per colonoscopy (OR, 2.08; 95% CI, 1.81–2.39, P < 0.001, I2 = 41%) and a 61% increase in the number of >5 mm adenomas detected per colonoscopy (OR, 1.61; 95% CI, 1.34–1.92, P < 0.001, I2 = 0%) with CAC compared to the control group. There was a 114% increase in sessile adenomas detected per colonoscopy (OR, 2.14; 95% CI, 1.82–2.53, P < 0.001, I2 = 22%) and a 127% increase in flat adenomas detected per colonoscopy (OR, 2.27; 95% CI, 1.83–2.82, P < 0.001, I2 = 0%) in the CAC group compared to the control group. CONCLUSION: The results of the present study demonstrate the promise of CAC in improving adenoma and polyp detection rates during routine colonoscopies across a spectrum of size and morphological characteristics.Figure 1.: Forrest plot of pooled estimates of adenoma detection rate using CAC compared to traditional colonoscopy.Figure 2.: Forrest plot of pooled estimates of polyp detection rate using CAC compared to traditional colonoscopy.Figure 3.: Forrest plot of pooled estimates of adenomas 0–5 mm (top) and >5 mm (bottom) detected per colonoscopy using CAC compared to traditional colonoscopy.
A 65-year old male with prior laryngeal cancer with radiation-induced esophageal stricture presented with abdominal pain. CT demonstrated a 1.3cm dilated lower CBD with stones, which was confirmed by MRCP. Standard ERCP could not be performed due to esophageal stricture. Given this, a decision was made to proceed with laparoscopic-assisted ERCP. The patient was taken to the OR, where he first underwent laparoscopic cholecystectomy. Subsequently, gastrotomy with 14 mm trocar placement was performed, through which the ERCP scope was introduced. Multiple attempts to cannulate the ampulla were made but due to a very distal position of the ampulla in the duodenum attempts were unsuccessful. Thus,the decision was made to remove the cholecystectomy clips and to attempt an intraoperative rendezvous procedure. A 0.035 guidewire was inserted using laparoscopic techniques through the cystic duct into the bile duct and eventually into the duodenum. The guidewire was grasped with rat tooth forceps by a gastroscope and brought out through the gastrostomy port. The duodenoscope was backloaded over the wire and bile duct access was then easily achieved. Sphincterotomy and balloon sphincteroplasty were performed, with retrieval of two large CBD stones. Patient tolerated the procedure without complications. Technique Highlights: ERCP is commonly used in the treatment of biliary disorders in patients with normal abdominal anatomy. However, in patients with altered anatomy, particularly those who have undergone Roux-en-Y gastric bypass, this method may be challenging. Several alternative techniques have involved the use of balloon enteroscopy or laparoscopy to facilitate access to the duodenum. Studies have shown higher success rates with laparoscopic assisted approaches. Laparoscopic-assisted ERCP allows access to the duodenum through a surgical gastrotomy. In cases, such as presented here, where cannulation remains difficult, a unique “rendezvous” technique can be attempted if surgical clips are removed. In this case, precut was avoided and hence exposing the patient to increased risk of bleeding and pancreatitis.
Polyps at the appendiceal orifice (AO) are rare and can pose unfamiliar endoscopic territory to colonoscopists. AO polyps pose a risk for appendiceal obstruction and resulting appendicitis in addition to malignant potential. Surgical removal via appendectomy or ileocecal resection has traditionally been indicated for such polyps but is associated with increased patient risk and cost. Currently, there is a lack of alternative methods for polyp resection. We describe a case of successful endoscopic AO polyp endoscopic mucosal resection (EMR) using two forceps introduced with a double-channel colonoscope. A 69-year-old male with a history of multiple colonic polyps was referred to our institution for removal of a polyp at the appendiceal orifice. Cecal intubation during colonoscopy showed a 4mm polypoid lesion extending down into the appendix. EMR was attempted and a modest lift of the polyp attained. Most of the polyp was removed with jumbo biopsy forceps, but it remained unclear if the entirety of the polyp was visible. A therapeutic double channel colonoscope was introduced, enabling the use of two biopsy forceps. One forceps was used to grasp the edge of the AO and stretch the tissue laterally, thus exposing the area within the AO that was previously not visualized. The other forceps was used to completely resect the remainder of the polyp. The same technique was used to apply argon plasma coagulation (APC) to the entire polypectomy defect. There were no adverse events, including bleeding or perforation. Follow-up colonoscopy with biopsy of the site three months later showed complete resection of the polyp. Technique Highlights: Most AO polyps are removed surgically. Surgery of any type poses increased healthcare costs to the patient and hospital, as well as complications related to anesthesia, infection, scarring, and bleeding, among others. Other previously described methods of AO polypectomy include underwater EMR, over-the-scope clip-assisted resection, and use of loop diathermy. Our method resection utilized less potentially expensive equipment, allowed the endoscopist to obtain a better view of the polyp, and resulted in complete resection without complications. Additional study is needed to determine the efficacy and safety of our double forcep method in the resection of inconveniently located polyps.Figure: Initial view of the AO polyp.Figure: Grasping of the polyp with one forceps while the other is being used to resect the remainder.Figure: Follow-up colonoscopy 3 months after polypectomy showing complete resection of the polyp.
