The Safety of Endosonography-Guided FNA and/or Trucut Biopsy in Patients on Aspirin, NSAIDs or Prophylactic Low Molecular Weight Heparin

The Safety of Endosonography-Guided FNA and/or Trucut Biopsy in Patients on Aspirin, NSAIDs or Prophylactic Low Molecular Weight Heparin John Meenan, Laura Doig, Charles Vu Background: Endoscopic ultrasound (EUS)-FNA is classified as a high risk procedure for gastrointestinal bleeding under the American Society of Gastrointestinal Endoscopy guidelines. Limited data suggest that aspirin and other non-steroidal anti-inflammatory drug (NSAIDs) in standard doses do not increase the risk of significant bleeding after EGD or colonoscopy with biopsy, polypectomy or biliary sphincterotomy. Because of the paucity of data, the same recommendation is extrapolated to EUS-FNA. Aim: To compare the safety of EUS-guided FNA or trucut biopsy (TCB) in patients who are taking aspirin, NSAIDs or prophylactic low molecular weight heparin (LMWH) and those who are not. Methods: Consecutive patients undergoing EUS FNA or TCB were prospectively analyzed for all complications. We excluded patients on non-aspirin antiplatelet drugs from EUS-FNA or TCB because of their profound effect on platelets. Cystic aspirate cases were given routine antibiotic prophylaxis. All patients were assessed for evidence of immediate and late (by a phone call within 48hours for outpatient or by review as inpatient) complications after the procedure. Bleeding was considered significant if there was: hematemesis, melena, continuous intraluminal oozing requiring hemostatic procedures or EUS evidence of an expanding hypoechoic area extraluminally. Results: 224 patients underwent EUS-FNA or TCB on 243 sites (153 pancreatic, 55 intraabdominal, 34 mediastinal, 1 rectal), of which 194 were solid, 46 cystic and 3 ascites. One (3.6%) of 28 patients taking potentially risky drugs (23 aspirin/NSAIDs and 5 LMWH) developed extraluminal bleeding compared to 5 (2.6%) of the remaining 196 patients (p Z 0.263). None of these patients developed any clinically significant sequel. One patient from the low-risk group developed intraluminal bleeding requiring injection therapy and hemoclipping. Two patients (one from each group) reported self limiting mild hematemesis. One patient (0.65%) developed pancreatitis. There was no difference in the bleeding complications between the FNA and TCB group (p Z 0.246). Conclusion: EUS-FNA or TCB appears to be safe in patients taking aspirin, NSAIDs or prophylactic LMWH. W1256 Transrectal Ultrasound (TRUS) Helps Select Patients for Transanal Excision (TAE) of Early (T1) Rectal Cancers and Large Polyps Girish Mishra, Saulette Roberson, John Sweeney, Edward Levine, Russell Howerton, Greg Waters Background and Significance: TAE is an extremely effective and attractive surgical approach in patients with T1 rectal cancers and polyps that are not amenable to endoscopic removal. T2 rectal cancers have a higher local recurrence rate and may be selected for more invasive surgery with either a low anterior resection,or an abdomino perineal resection. Thus, accurate staging is critical in selecting patients for a TAE. TRUS is highly sensitive in T and N-staging for rectal cancer, but its diagnostic accuracy for distinguishing T1 and T2 rectal cancers has been challenged. Study Aims: To determine the accuracy of TRUS in determining resectability by TAE for T1 rectal cancers and polyps too large to be resected endoscopically. Methods: 183 TRUS were performed at our institution between August 2001 and October 2004. 21 TAE were performed for either T1 lesions by TRUS or for large polypoid masses localized to the mucosa by TRUS, but technically challenging to remove endoscopically. Results: The mean age of patients staged either T1 or T2 was 62 (33-80). 13 of 15 patients (87%) were accurately classified as having T1 disease. 2 lesions were understaged. 6 polypoid lesions (100%) that were either tubulovillous or villous adenomas were accurately classified as being localized to the mucosa. All patients (nZ11) staged T2 by TRUS were confirmed to be T2 at pathology. No difference was noted in the predictive value of TRUS for T1 vs T2 lesions (pZ.4923, exact test). Correlation between TRUS and pathology was kZ.85.Conclusions: TRUS is highly accurate in delineating depth of invasion for T1 rectal cancers and large, polypoid lesions unamenable to polypectomy. The ability to accurately delineate T1 vs T2 rectal cancer by TRUS allows for the appropriate selection of patients for TAE and thus, avoidance of more invasive surgery with higher morbidity and mortality.