Basic technique in endoscopic ultrasound-guided fine needle aspiration for solid lesions: How many passes?

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has evolved to become an indispensable tool for tissue acquisition in patients with luminal and extra luminal gastrointestinal cancers. Despite the extensive use of EUS-FNA, there still exists a wide variation in the number of samples required to ensure acquisition of diagnostic material from different kind of lesions. There are several factors that may influence the number of fine needle passes made during EUS-FNA, but the main factor seems to be the presence of a Cytopathologist during the EUS procedure. The diagnostic yield of EUS-FNA with rapid on-site evaluation (ROSE) in most studies exceeds 90%. Nevertheless, ROSE is not available in many centers. Various studies have investigated the adequate number of needle passes that should be performed if ROSE is not used. Differences exist based on the nature of the target lesion: Five to seven passes for pancreatic masses, three passes for lymphnodes, only one pass for pancreatic cystic lesions. Consider using a core biopsy needle or a 19-G FNA needle for histology could improve the diagnostic yield. Even though EUS-FNA is widely available, some patients still do not receive conclusive diagnoses upon initial EUS-FNA. One way to maximize the benefits for patients might be to centralize cases to several well-equipped, high-volume centers with experienced endosonographers that have universal availability of ROSE.

Fetal radiation exposure: Is monitoring really needed?

The effect of fetal radiation during endoscopic retrograde cholangiopancreatography (ERCP) on pregnant women is a very interesting topic. Smith et al recently estimated the fetal radiation exposure in pregnant women undergoing ERCPs using thermoluminescent dosimeters (TLDs). The authors concluded that TLDs are unnecessary during ERCP with modified techniques. We believe that an extreme caution is needed in clinical practice before drawing such conclusions when they are not strongly supported by enough experimental evidence. Therefore, we recommend that fetal radiation exposure be monitored in clinical practice by using dosimeters, bearing in mind that all relevant techniques to control and minimize the exposure must be applied.

Feasibility and safety of EUS-guided cryothermal ablation in patients with locally advanced pancreatic cancer

BACKGROUND

New therapies are needed for pancreatic cancer.

OBJECTIVE

To determine the feasibility and safety of a new endoscopic treatment. Secondary endpoints were to determine effects on tumor growth measured with CT scan and to find the overall survival.

DESIGN

A cohort study of patients with local progression of advanced pancreatic adenocarcinoma after neoadjuvant therapy. The cryotherm probe (CTP), a flexible bipolar device that combines radiofrequency with cryogenic cooling, was used under EUS guidance.

SETTING

San Raffaele Hospital, Milan, Italy; University Medical Center, Hamburg-Eppendorf, Germany.

PATIENTS

A total of 22 patients (male/female 11/11; mean age 61.9 years) were enrolled from September 2009 to May 2011.

INTERVENTION

Radiofrequency heating: 18 W; pressure for cooling: 650 psi (Pounds per Square Inch); application time: depending on tumor size.

MAIN OUTCOME MEASUREMENTS

Feasibility was evaluated during the procedure. A clinical and radiologic follow-up was planned.

RESULTS

The CTP was successfully applied in 16 patients (72.8%); in 6 it was not possible because of stiffness of the GI wall and of the tumor. Amylase arose in 3 of 16 patients; none had clinical signs of pancreatitis. Late complications arose in 4 cases: 3 were mostly related to tumor progression. Median postablation survival time was 6 months. A CT scan was performed in all patients, but only in 6 of 16 was it possible to clearly define the tumor margins after ablation. In these patients, the tumor appeared smaller compared with the initial mass (P = .07).

LIMITATIONS

Small sample of patients, difficulty of objectifying the size of the ablated zone by CT scan.

CONCLUSION

EUS-guided CTP ablation is feasible and safe. Further investigations are needed to demonstrate progression-free survival and local control.

Single-step versus two-step endo-ultrasonography-guided drainage of pancreatic pseudocyst

OBJECTIVE

The aim of this prospective study was to compare the feasibility, technical success rate and complication between single-step endo-ultrasonography (EUS)-guided and two-step EUS-guided drainage technique for symptomatic pancreatic pseudocyst (PP).

METHODS

Twenty-one PP patients with clear intra-cystic fluid that needed to be drained were divided into two groups, depending on the availability of the therapeutic echoendoscope at the time of the procedure: Group 1 (13 patients) underwent a single-step EUS-guided endoscopic drainage and Group 2 (8 patients) underwent a two-step EUS-guided drainage technique.

RESULTS

In Group 1 immediate technical success was achieved in 92.3% (12/13); two patients had recurrent PP and both were successfully treated by a second EUS-guided drainage. Clinical success was achieved in all cases. In Group 2 technical success was achieved in 75.0% of the patients (6/8). One patient (12.5%) bled 36 h after the procedure. Five out of 6 patients had long-term success. Clinical success was significantly greater in Group 1 (P < 0.05).

CONCLUSION

The technique of single-step EUS-guided drainage was superior to the technique of a two-step EUS-guided drainage technique for PP drainage.

Celiac plexus block for pancreatic cancer pain in adults

BACKGROUND

Pancreatic cancer causes severe pain in 50 to 70% of patients and is often difficult to treat. Celiac plexus block (CPB) is thought to be a safe and effective technique for reducing the severity of pain.

OBJECTIVES

To determine the efficacy and safety of celiac plexus neurolysis in reducing pancreatic cancer pain, and to identify adverse effects and differences in efficacy between the different techniques.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, GATEWAY and EMBASE from 1990 to December 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of CPB by the percutaneous approach or endoscopic ultrasonography (EUS)-guided neurolysis in adults with pancreatic cancer at any stage, with a minimum of four weeks follow-up.

DATA COLLECTION AND ANALYSIS

We recorded details of study design, participants, disease, setting, outcome assessors, pain intensity (visual analogue scale (VAS)) and methods of calculation.

MAIN RESULTS

The search identified 102 potentially eligible studies. Judged from the information in the title and abstract six of these concerning the percutaneous block, involving 358 participants, fulfilled the inclusion criteria and were included in the review. All were RCTs in which the participants were followed for at least four weeks. We excluded studies published only as abstracts. We identified one RCT comparing EUS-guided or computed tomography (CT) -guided CPB but its aim was to assess efficacy in controlling chronic abdominal pain associated with chronic pancreatitis rather than pancreatic cancer, so it was excluded.For pain (VAS) at four weeks the mean difference was -0.42 in favour of CPB (95% confidence interval (CI) -0.70 to - 0.13, P = 0.004, fixed-effect model). At eight weeks the mean difference was -0.44 (95% CI -0.89 to - 0.01, random-effects model). At eight weeks there was significant heterogeneity (I(2) = 89%).Opioid consumption was significantly lower in the CPB group than the control group (P < 0.00001). 

AUTHORS' CONCLUSIONS

Although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients. Further studies and RCTs are recommended to demonstrate the potential efficacy of a less invasive technique under EUS guidance.

Pancreatic endoscopic ultrasound-guided fine needle aspiration: complication rate and clinical course in a single centre

BACKGROUND

Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) is effective for obtaining biopsy specimens from pancreatic lesions.

AIM

To determine the frequency and severity of complications after EUS-FNA of solid and cystic pancreatic lesions in a single centre large series of patients.

PATIENTS AND METHODS

From January 2005 to December 2008, information on all patients referred to our unit for pancreatic EUS was systematically entered in a computer database including clinical and morphologic data. Records were reviewed to evaluate whether complications such as haemorrhage, acute pancreatitis, intestinal perforation, or others occurred after EUS-FNA of the pancreas.

RESULTS

A total of 3296 pancreatic EUS were done in four years. In the 1034 pancreatic EUS-FNA, we observed 10 (0.96%) haemorrhages (7 intracystic, 2 in the pancreatic duct, and 1 in a small carcinoma), 2 (0.19%) acute severe pancreatitis and 1 (0.09%) duodenal perforation followed by complicated post-surgical hospitalization and death. The haemorrhages were all self-limiting. Overall, major complications (pancreatitis and perforation) arose in 0.29% of these examinations.

CONCLUSIONS

EUS-FNA is safe, with a low risk of severe haemorrhage. Although rare, acute pancreatitis is generally mild or severe, requiring prolonged hospitalization. One fatal complication occurred after duodenal perforation in a patient with duodenal neuroendocrine tumour and pancreatic infiltration.

US-guided application of a new hybrid probe in human pancreatic adenocarcinoma: an ex vivo study

BACKGROUND

Ablative therapies such as radiofrequency and cryotechnology are widely used in oncological intervention but not in the pancreatic field because of their high operative risks. A new flexible bipolar ablation device (Cryotherm probe [CTP]) was developed combining radiofrequency and cryotechnology.

OBJECTIVE

To evaluate the efficacy of the CTP in destroying neoplastic tissue of explanted pancreatic tumors of patients with pancreatic adenocarcinoma.

DESIGN

Ex vivo clinical study.

SETTING

Inpatient hospital setting.

PATIENTS

This study involved 16 explanted pancreatic tumors from 16 patients.

INTERVENTIONS

CTP application was performed on explanted pancreatic tumors. Anatomic specimens were divided into 4 groups; each group received a predefined application time of 120 to 600 seconds.

MAIN OUTCOME MEASUREMENTS

The coagulation diameter (short axis) perpendicular to the device's longitudinal axis was used as the primary outcome measure.

RESULTS

All pancreatic specimens showed histological signs of coagulative necrosis. There was a positive correlation between the short axis of the obtained necrosis and duration of application (r = 0.74).

LIMITATIONS

This study was an ex vivo study with all limitations typical of this kind of study.

CONCLUSIONS

The CTP is effective in destroying neoplastic pancreatic tissue, creating an ablation zone, the extent of which is related to the duration of application.