Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Drainage in Patients With Acute Cholecystitis Undergoing Elective Cholecystectomy

INTRODUCTION

Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD.

METHODS

A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared.

RESULTS

One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324).

DISCUSSION

Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

Endosonography-Guided Tissue Acquisition for Diagnosis of Squamous Carcinoma of the Pancreas: A Report of Three Cases

While approximately 85% of neoplasms are ductal pancreatic adenocarcinomas (DPA), adenosquamous pancreatic carcinoma (APC) is a rare subtype of pancreatic cancer that exhibits aggressive behavior and poor prognosis. The authors report three cases of primary APC diagnosed through endoscopic ultrasound-guided tissue acquisition (EUS-TA) using the new ProCore 20G needle, which had been developed to improve fine-needle aspiration results by providing more tissue for histopathology. Given its ability for microcore retrieval, pancreatic stroma examination, and excellent histopathology results, EUS-TA has exhibited exceptional diagnostic yield among patients with solid pancreatic lesions. All three APC cases presented herein had been accurately diagnosed using immunohistochemistry after microcore acquisition.

Retroperitoneal Bronchogenic Cyst Mimicking a Pancreatic Cystic Lesion with Extremely High Level of Intralesional Fluid CA-19.9 Antigen: Benign in Disguise

Bronchogenic cysts are congenital benign tumors resulting from abnormal budding of the primitive foregut. Usually presented on the posterior mediastinum, its presence on the retroperitoneum is extremely rare. We present an asymptomatic lady patient with a retroperitoneal cystic lesion that was submitted to endoscopic ultrasound-guided biopsies and intracystic fluid aspiration with histology excluding malignance despite intracystic fluid biochemical analysis that disclosed extremely high carbohydrate antigen 19-9. Definite diagnosis of bronchogenic cyst was only possible after complete surgical resection of the lesion. Furthermore, we discuss the use of this antigen as a tumor marker in this situation and its relevance to the preoperative diagnosis of such lesions.

Yield of surgery in solid pseudopapillary neoplasms of the pancreas: A case series and literature review

BACKGROUND

Solid pseudopapillary neoplasms (SPN) of the pancreas represents approximately 2% of non-endocrine tumors of the pancreas. It is described in the literature as a rare and predominant tumor in young women.

AIM

To report a case series with SPN and analyzing clinical, surgical, anatomopathological characteristics, as well as the prognosis and review of literature.

METHODS

Retrospective analysis of patients undergoing surgery, with histological diagnosis of SPN between 1998 and 2018, using standardized and prospectively completed forms, performed at the Surgery Service of the Upper Digestive System at Hospital São Rafael/Rede D’Or in Salvador - BA. Review of literature through a database search in MEDLINE/PubMed of retrospective articles.

RESULTS

Fourteen female patients with the average age of 31.6 years (range min-max) were selected. Twelve patients (85.7%) were asymptomatic, being an incidental diagnosis or due to screening for other reasons. One patient had abdominal pain due to gastric compression and another patient had jaundice. The 14 patients were staged with computerized tomography or magnetic resonance imaging. None had evidence of metastasis. In 8 patients (57.1%), the tumor was in the tail and body. The average size was 6.7 cm (range min-18). The type of surgery was according to the anatomical location of the tumor. There was no lymph node involvement. In two cases, vascular resection with the use of a prosthesis was required for reconstruction. The surgical margins were free. In all cases, postoperative immunohistochemistry confirmed that it was a solid pseudo-papillary neoplasia of the pancreas. There has been no disease recurrence in any case so far.

CONCLUSION

The tumors had a benign, indolent and histopathological behavior compatible with the literature. Curative surgery is recommended in all cases.

Nonsteroidal anti-inflammatory drug effectivity in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct. Although the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis [post-ERCP pancreatitis (PEP)], bleeding and perforation.

AIM

To assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in preventing PEP during follow-up.

METHODS

Databases such as MEDLINE, EMBASE and Cochrane Central Library were searched. Only randomized controlled trials (RCTs) comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes evaluated included the incidence of PEP, severity of pancreatitis, route of administration, types, dose, and timing of administration of NSAIDs.

RESULTS

Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed. Overall, 4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs (control group). Ultimately, 298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group. The risk of PEP was lower in the NSAID group risk difference (RD): -0.04; 95% confidence interval (CI): -0.07 to - 0.03; number needed to treat (NNT), 25; P < 0.05. NSAID use effectively prevented mild pancreatitis compared to placebo use (2.5% vs 4.1%; 95%CI: -0.05 to -0.01; NNT, 33; P < 0.05), but information on moderate PEP and severe PEP could not be fully elucidated. Only rectal administration reduced the incidence of PEP with RD: -0.06; 95%CI: -0.08 to -0.04; NNT, 17; P < 0.05). Furthermore, only the use of diclofenac or indomethacin was effective in preventing PEP, at a dose of 100 mg, which must be administered before performing ERCP.

CONCLUSION

Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP. Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.

EUS-FNA Diagnosis with Core Biopsy of Pancreatic Metastases from Primary Breast Cancer

Background

The pancreas as a site of metastasis of other primary tumors is a rare event. Pancreatic metastases may occur years after the start of treatment of a neoplasm of another organ or may be the initial manifestation of an unidentified primary tumor. The most commonly reported primary sites for pancreatic metastases are the kidneys, lungs, breast, bowel, and skin (melanoma). Case Summary. The authors report a case of pancreatic metastasis derived from a primary breast cancer that underwent endoscopic ultrasound fine-needle aspiration (EUS-FNA) core biopsy to obtain tissue, which made it possible to perform an immunohistochemical study.

Conclusion

We emphasize the importance of outpatient follow-up after the treatment of a neoplasia and the completion of control exams. In addition, we should always be aware of the finding of a secondary lesion in patients who have already been diagnosed with cancer, even if it is located in unusual organs, as in this case, where two metastases of a breast carcinoma to the pancreas were detected.

Adverse events and mortality: comparative analysis between diagnostic and interventional endoscopic ultrasound

BACKGROUND AND AIMS

Escalating an indication of EUS for diagnosis and treatment justifies the evaluation of the conditions associated with the adverse events (AE) and related deaths. The aim is to evaluate and compare the incidence of AE and deaths after diagnostic-EUS (D-EUS) and interventional-EUS (I-EUS).

METHODS

This retrospective study included patients undergoing D-EUS and I-EUS, in two centers for 28 years (03/1992 to 12/2019). Were noted parameters such as: age, gender, indication of EUS, modality, time of occurrence and severity of AE, type of treatment imposed and whether there was death. Descriptive analysis was performed using means, standard deviation and frequencies of the variables of interest.

RESULTS

13,196 procedures performed, 9843 D-EUS and 3353 I-EUS. Thirty-seven (0.3%) had AE with six deaths (0.04%). The overall rate of AE for D-EUS and I-EUS was 0.08% and 0.86%, respectively (p > .05). Three deaths (0.03%) occurred after D-EUS and three (0.09%) after I-EUS. AE were immediate and early in 70% and 30%, respectively, with no late complications. Perforation was detected immediately in 80% and early in 20%, being more frequent after D-EUS than I-EUS. Acute pancreatitis occurred immediately in 70% and early in 30%. The AE were mild, moderate, and severe in 35.1%, 27%, and 37.8%, respectively. Overall, D-EUS presented the majority of AE as severe (87.5%), while I-EUS presented mild AE in most cases (41.4%), followed by severe complications (24.1%).

CONCLUSIONS

Despite the low incidence of AE and mortality after EUS, the occurrence of severe complications, especially perforation in D-EUS, may support the review of therapeutic protocols, aiming to ensure that a quality and safety process is implemented in the practice of EUS.

Different options of endosonography-guided biliary drainage after endoscopic retrograde cholangio-pancreatography failure

AIM

To investigate the success rates of endosonography (EUS)-guided biliary drainage (EUS-BD) techniques after endoscopic retrograde cholangiopancreatography (ERCP) failure for management of biliary obstruction.

METHODS

From Feb/2010 to Dec/2016, ERCP was performed in 3538 patients, 24 of whom (0.68%) suffered failure to cannulate the biliary tree. All of these patients were initially submitted to EUS-guided rendez-vous (EUS-RV) by means of a transhepatic approach. In case of failure, the next approach was an EUS-guided anterograde stent insertion (EUS-ASI) or an EUS-guided hepaticogastrostomy (EUS-HG). If a transhepatic approach was not possible or a guidewire could not be passed through the papilla, EUS-guided choledochoduodenostomy (EUS-CD) was performed.

RESULTS

Patients were submitted to EUS-RV (7), EUS-ASI (5), EUS-HG (6), and EUS-CD (6). Success rates did not differ among the various EUS-BD techniques. Overall, technical and clinical success rates were 83.3% and 75%, respectively. Technical success for each technique was, 71.4%, 100%, 83.3%, and 83.3%, respectively (P = 0.81). Complications occurred in 3 (12.5%) patients. All of these cases were managed conservatively, but one patient died after rescue percutaneous transhepatic biliary drainage (PTBD).

CONCLUSION

The choice of a particular EUS-BD technique should be based on patient’s anatomy and on whether the guidewire could be passed through the duodenal papilla.

Comparative Study between Plastic and Metallic Stents for Biliary Decompression in Patients with Distal Biliary Obstruction

This paper presents a retrospective comparison of plastic versus metallic stents in the drainage of malignant distal biliary obstructions. We compared single plastic stents (SPS), multiple plastic stents (MPS), and metallic stents (SEMS) regarding clinical decrease of TB < 2.0 mg/dL, long-term patency, and adverse event. 58 patients (38 women) with MDBO were included. Diagnoses were 44 pancreatic adenocarcinoma (74.6%), 9 metastasis (15.5%), 3 pancreatic neuroendocrine tumors (5.1%), and 2 adenocarcinoma in the major papilla (3.4%). The number of patients included in the SPS, MPS, and SEMS was 17, 6, and 35, respectively. Comparing the survival curves with respect to obstruction, we observed a lower mean permeability of the SPS compared to that of the MPS with p < 0.003 and of the SEMS group (p < 0.01). There was no statistical difference between the use of MPS, despite the small number of patients compared to the use of SEMS (p < 0.13) to reach the satisfactory levels of bilirubin.

Accuracy of endoscopic ultrasound-guided fine-needle aspiration in the suspicion of pancreatic metastases

Background

Metastases to the pancreas are rare, and usually mistaken for primary pancreatic cancers. This study aimed to describe the histology results of solid pancreatic tumours obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of metastases to the pancreas.

Methods

In a retrospective review, patients with pancreatic solid tumours and history of previous extrapancreatic cancer underwent EUS-FNA from January/1997 to December/2010. Most patients were followed-up until death and some of them were still alive at the end of the study. The performance of EUS-FNA for diagnosis of pancreatic metastases was analyzed. Symptoms, time frame between primary tumour diagnosis and the finding of metastases, and survival after diagnosis were also analyzed.

Results

37 patients underwent EUS-FNA for probable pancreas metastases. Most cases (65%) presented with symptoms, especially upper abdominal pain (46%). Median time between detection of the first tumour and the finding of pancreatic metastases was 36 months. Metastases were confirmed in 32 (1.6%) cases, 30 of them by EUS-FNA, and 2 by surgery. Other 5 cases were non-metastatic. Most metastases were from lymphoma, colon, lung, and kidney. Twelve (32%) patients were submitted to surgery. Median survival after diagnosis of pancreatic metastases was 9 months, with no difference of survival between surgical and non-surgical cases. Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA with histology analysis of the specimens for diagnosis of pancreatic metastases were, respectively, 93.8%, 60%, 93.8%, 60% and 89%.

Conclusion

EUS-FNA with histology of the specimens is a sensitive and accurate method for definitive diagnosis of metastatic disease in patients with a previous history of extrapancreatic malignancies.

Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging

CONTEXT

The identification of a bulging covered by normal epithelium is a common finding during an upper gastrointestinal endoscopy.

OBJECTIVE

To compare the endoscopic and endosonography findings in the differential diagnosis of the gastrointestinal bulging (subepithelial tumor or extrinsic compression).

METHOD

Patients referred by endosonography with bulging of upper gastrointestinal tract were studied retrospectively. The size, location, consistency and presumptive diagnosis were recorded at time of endoscopy and endosonography. Endosonography-guided fine-needle aspiration was proposed in case of uncertain diagnose to increase diagnostic sensitivity.

RESULTS

One hundred seventy-six patients (93 women) and mean age 62.5 years (10-87). One hundred fifty-three had subepithelial tumor and 23 had extrinsic compression as a final diagnosis. Endosonography had sensitivity, specificity and accuracy higher than those found by endoscopy for both diagnosis subepithelial tumor and extrinsic compression. Endoscopy and endosonography showed poor concordance (K = 0.13) for subepithelial tumor diagnosis and unsuitable agreement for diagnosis in extrinsic compression (K = 0.01). The endosonography-guided fine-needle aspiration had sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 75%, 72.4%, 80.5%, 65.6% and 74%, respectively.

CONCLUSION

Endoscopy has high sensitivity and low specificity for subepithelial tumor and both are low for the extrinsic compression. Endoscopy is a good tool for diagnosis of the subepithelial tumors, but not to determine the cause of an extrinsic compression. The endosonography identifies the layer from which subepithelial tumor comes, obtain histological samples, and increasing the diagnostic accuracy.

Current role of imaging methods in the diagnosis of cystic solid pancreas neoplasms: part II

The authors address the value of endoscopic retrograde cholangiopancreatography, ultrasonography, computed tomography, magnetic resonance imaging and endoscopic ultrasound for the diagnosis of cystic and solid neoplasms of the pancreas, demonstrating that each of them is of great importance to undoubtedly increase the diagnostic accuracy of the biliopancreatic system diseases. The best method for each of several tumors is then determined.

Clinicopathologic characteristics and endoscopic treatment of post-traumatic pancreatic pseudocysts

OBJECTIVE

Surgery is the treatment of choice for traumatic pseudocyst. Minimally invasive management of these collections has been used. The aim was to analyze the outcome after endoscopic treatment and the integrity of the main pancreatic duct caused by abdominal trauma.

METHODS

A total of 51 patients with traumatic pseudocyst who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Endoscopic retrograde pancreatography allowed characterization according to Takishima classification (1, 2, and 3), in which guided therapy was divided into transpapillary drainage (Takishima 2 and 3 without bulging), transmural (type 1), or combined (type 2 or 3 with bulging).

RESULTS

Endoscopic retrograde pancreatography was obtained in 47 (90%) of 51 patients. Drainage was transmural in 13, combined in 24, and transpapillary in 10. The success and recurrence rates of endoscopic treatment were 94% and 8%, respectively. There were 9 complications but no procedure-related deaths. Patients with penetrating trauma had more recurrences (P = 0.01) and risk for development of infection (P = 0.045) than those with blunt trauma.

CONCLUSIONS

Endoscopic treatment of traumatic pancreatic collection is safe and effective and can be considered a first-choice alternative to surgical treatment. Endoscopic retrograde pancreatography and Takishima classification are useful in determining the best endoscopic approach.

Endoscopic ultrasound-guided biopsies for mediastinal lesions and lymph node diagnosis and staging

OBJECTIVES

To disseminate transesophageal ultrasound-guided fine needle aspiration (EUS-FNA) as an alternative to investigate mediastinal tumoral lesions because it is an underused modality that has been available in Brazil for more than 15 years.

METHODS

Descriptive analysis of a single endoscopy service's experience since 1997 in the accomplishment of EUSFNA for mediastinal staging of previously known malignancies (Group 1) or diagnostic definition of suspect lymph nodes and masses (Group 2).

RESULTS

EUS-FNA was performed in 51 patients between 26 and 87 years of age. The diameter of the lesions ranged between 1.1 and 9.8 cm (mean 3.9 cm). Their location corresponded to the following stations: higher paratracheal (4 cases), lower paratracheal (7), aortic window (12), para-aortic (6), subcarinal (9), paraesophageal (8), and hilar (5). In Group 1, 17 patients had previously diagnosed primary lung (9), breast (4), kidney (2), colon (1), and bladder (1) cancer. Fifteen of these punctures were positive for malignity. Two others were later submitted to mediastinoscopy, which identified metastases not detected by EUS-FNA. Group 2 comprised 34 patients. Among these patients, EUS-FNA diagnosed 22 neoplasms, five cases of tuberculosis and two duplication cysts. Cytology was inconclusive or without a specific diagnosis in five other cases. Mediastinoscopy identified two undiagnosed cases of oat-cell carcinoma, one lymphoma and one cryptococcosis, and confirmed one reactive lymphadenitis. There were no complications related to the method.

CONCLUSIONS

EUS-FNA obviated the need for surgical procedures in 86.3% of cases. Therefore, oncologists, pulmonologists, and thoracic surgeons should always remember the technique's potential and availability.

Endoscopic ultrasound-guided fine-needle aspiration using helical computerized tomography for TN staging and vascular injury in operable pancreatic carcinoma

CONTEXT

EUS-FNA is increasingly being used in operable pancreatic carcinoma cases identified by CT.

OBJECTIVES

Determine the safety, accuracy and clinical utility of EUS-FNA for T, N and TN staging and vascular injury assessment in proven ductal pancreatic carcinoma.

PATIENTS

Fifty-two consecutive patients (29 women and 23 men) with histologically ductal pancreatic carcinoma, with an excellent possibility of mass resection assessed by helical computerized tomography, were studied. Mean age was 62.4 years (range: 27-82 years). Tumor locations were in the head (43 cases), body (5 cases) and tail (4 cases) of the pancreas. Mean tumor size from EUS was 3.7 cm (range: 0.8-6.2 cm).

METHODS

We reviewed medical records and abdominal ultrasound, CT, EUS-FNA and the results were compared to surgical and histological findings.

RESULTS

Ultrasound identified pancreatic abnormalities in 38 out of 52 patients (73.1%): pancreatic mass (25 cases), pancreatic head enlargement (8 cases), dilation of main pancreatic duct (3 cases), pancreatic cyst (1 case) and pancreatic calcification (1 case). CT showed a pancreatic mass (30 cases), pancreatic enlargement (17 cases), pancreatic cystic lesion (2 cases) and pancreatic calcification (1 case) in 50 out of 52 patients (96.2%). EUS-FNA found a clear pancreatic tumor image in all patients (100%). The accuracy of EUS for evaluating portal blood vessels, superior mesenteric artery, T alone, N alone and combined TN staging was 86.5%, 94.2%, 84.7%, 67.3% and 55.8%, respectively. In addition to cytological material from 50 patients, microfragments from 43 patients were sent for histological analysis. Two patients (3.8%) showed minor complications: self-limited bleeding and acute pancreatitis.

CONCLUSIONS

EUS-FNA is safe, and can help gastroenterologists and surgeons make surgical decisions regarding pancreatic carcinoma patients.

Single-step EUS-guided endoscopic treatment for sterile pancreatic collections: a single-center experience

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS) is useful for the treatment of sterile pancreatic fluid collections (PFC), either by means of transmural drainage or by complete aspiration. The aim of this study was to evaluate the efficacy and safety of single-step EUS-guided endoscopic approaches for treatment of sterile PFC.

PATIENTS AND METHODS

During a 3-year period, 77 consecutive patients with symptomatic, persistent sterile PFC were evaluated and treated with the linear EUS. We excluded patients with grossly purulent collections, chronic pseudocyst and those whose cytology diagnostic was neoplastic cyst of pancreas. 44 patients received a single 10-Fr plastic straight stent under EUS or fluoroscopic control (group I) and 33 of these underwent a single-step complete aspiration with a 19-gauge needle (group II).

RESULTS

The mean size of the sterile PFC was 48 mm in group I and 28 mm in group II (p < 0.001). Overall, endoscopic treatment was successful in 70 (90.9%) patients. The mean volume aspirated was 25 (18-65) ml. The total number of procedures was 50 in group I and 41 punctures in group II. After a mean follow-up of 64 +/- 15.6 weeks there were 6 complications (13.6%): 2 recurrences (referred to surgery), 2 developing abscesses (submitted a new EUS-guided endoscopic drainage with success), 1 perforation that died (2.2%), and 1 case of bleeding (sent to surgery) in group I. In group II there were only 6 (18.1%) recurrences (submitted a new EUS-guided aspiration). None of the patients undergoing single-step aspiration developed infections, perforation or hemorrhage.

CONCLUSION

The recurrence of pancreatic pseudocysts after endoscopic treatment was similar, either by means of plastic stents or by complete single-step aspiration.

Cell block technique and cytological smears for the differential diagnosis of pancreatic neoplasms after endosonography-guided fine-needle aspiration

Cytological smear is widely employed to analyse specimens obtained from endosonography-guided fine-needle aspiration (EUS-FNA), but false-negative or inconclusive results may occur. A better diagnostic yield can be obtained from processing cell blocks. We compared the effectiveness of the cell block technique and cytological smear in the diagnosis of pancreatic neoplasms. From January 1997 to December 2006, 611 patients with pancreatic tumors were evaluated by EUS-FNA. Surgery was performed in 356 cases, and the other 255 patients were followed clinically for an average of 12.8 months. In total, 282 (46.2%) patients were evaluated with cytological smears, and 329 (53.8%) were evaluated using only cell blocks. Malignant disease was detected in 352 (57.6%) cases, in which adenocarcinoma accounted for 236 (67%) cases. A benign disease was found in the other 259 cases, including 35.1% focal chronic pancreatitis and 32.4% pseudocysts. Aspiration samples were satisfactory in 595 (97.4%) patients after an average of 2.2 (1-4) passes of the needle. Regardless of the cytopathological examination technique, EUS-FNA confirmed malignancy in 269 of 352 (76.4%) cases, and a benign disease in 257 of 259 (99.2%) cases. For patients who received surgery with histologically confirmed lesions, the sensitivity specificity, positive and negative predictive values, and accuracy of the smears versus cell blocks in diagnosing pancreatic tumors were 61% versus 85.2% (P<0.001), 100% versus 93.1%, 100% versus 98.4%, 36% versus 55.1% (P=0.046) and 68% versus 86.5% (P<0.001), respectively The cell block technique demonstrated a hig her sensitivity, negative predictive value and accuracy than cytological smears.

[Early pancreatic cancer: can the methods currently available identify this disease?]

OBJECTIVES

Call attention of the gastroenterologists and surgeons on the patients with high risk of developing pancreatic carcinoma, and whether or not forms of surveillance and prevention of this disease, which can be applied to daily clinical practice. DATA SURVEY: It was used the database of PubMed (US National Library of Medicine), looked up the publications of recent years for the groups at risk, molecular biological testing and methods of image used in the identification of small tumors of the pancreas.

BACKGROUND

The survival rates of adenocarcinoma of the pancreas remain negligible, even after the significant advances in diagnosis by imaging, treatment and understanding of the molecular biology of this disease. Although embryonic strategies for surveillance and prevention for people with high risk of pancreatic cancer has developed.

CONCLUSIONS

This review summarizes how to identify people at high risk of developing this disease and what is the state of the art of genetic counseling and screening through techniques of image available.

Endoscopic ultrasound guided fine-needle aspiration core biopsy: comparison between an automatic biopsy device and two conventional needle systems

BACKGROUND

endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis.

OBJECTIVE

to compare samples obtained with EUS-FNA using 3 different needle systems: GIP, NA-10J-1 and Shot-Gun.

METHODS

19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination.

RESULTS

mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Specimens adequate for cytologic diagnosis were obtained in 13/19 (68. 4%) patients using GIP model, in 14/19 (73.7%) with NA10J-1 model, and in 17/19 (89.5%) with ShotGun, model (p=0.039). Histologic analysis was possible in 10/19 (52.6%) patients using the GIP model, in 14/19 (73.7%) with NA10J-1, and in 17/19 (89.5%) with Shot-Gun, model (p=0.005). Adequate samples for cytologic or histologic assessment in 16/19 (84.2%) patients using the GIP model, in 17/19 (89.5%) with NA10J-1, and in 18/19 (94.7%) with Shot-Gun, model (p=0.223). In two cases biopsies were negative due to very hard tumors.

CONCLUSION

the Shot-Gun needle obtained better samples for histological diagnosis than NA10J-1 needle and GIP.

Endoscopic ultrasound and fine needle aspiration in chronic pancreatitis: differential diagnosis between pseudotumoral masses and pancreatic cancer

CONTEXT

Pseudotumoral chronic pancreatitis can be difficult to differentiate from pancreatic carcinoma.

OBJECTIVE

To evaluate the role of endoscopic ultrasound and fine needle aspiration in differentiating between inflammatory masses and malignancies in chronic pancreatitis.

DESIGN

Retrospective study.

SETTING

Tertiary care endoscopy unit.

PATIENTS AND INTERVENTIONS

Between February 1997 and December 2006, 69 pancreatic head masses from patients with alcoholic chronic pancreatitis underwent EUS-FNA using a linear echoendoscope and 22-gauge needles. Final diagnoses were obtained from surgery or clinical follow-up. The patients were subdivided into two groups: pseudotumoral chronic pancreatitis and pancreatic cancer.

RESULTS

Pseudotumoral masses and adenocarcinoma were found in 58 and 11 patients, respectively. The size of the lesions and the clinical presentation were similar in both groups, but the cancer patients were older than the patients with pseudotumoral masses (P=0.020). Fourteen of the 58 (24.1%) pseudotumoral masses were misdiagnosed as cancers, and 4 of the 11 (36.4%) cancers were erroneously diagnosed as pseudotumoral masses when evaluated by EUS alone. EUS-FNA confirmed the final diagnosis in 66 of the 69 (95.7%) cases. Cytopathology correctly classified 8 of the 11 (72.7%) malignancies and all benign cases. Three of the 11 (27.3%) cancers were misdiagnosed as pseudotumoral masses, and no pseudotumoral mass was diagnosed as a cancer. In two cases, the specimens were inadequate for cytopathological assessment. The sensitivity, specificity, positive and negative predictive values, and the diagnostic accuracy of EUS-FNA were 72.7%, 100%, 100%, 95.1% and 95.7%, respectively.

CONCLUSIONS

The diagnostic accuracy of endoscopic ultrasound alone for differentiating between pseudotumoral masses and pancreatic cancer arising from chronic pancreatitis is unsatisfactory. Fine needle aspiration of these tumors significantly improves diagnostic capability.

Conservative management of esophageal perforation following obesity surgery

CONTEXT

Laparoscopic adjustable silicone gastric banding (LASGB) is one of the several surgical techniques for treating patients with morbid obesity. Erosion and perforation in the gastric chamber caused by LASGB are rare complications that have already been described. There have not yet been any reports of perforation of the middle esophagus during this procedure.

CASE REPORT

The authors describe the case of a patient who presented the complication of very extensive perforation of the middle third of the esophagus following LASGB. This was successfully managed using conservative treatment.