Background and Aims A new core biopsy needle with a novel tip, opposing bevel, and sheath design has recently been introduced for EUS-guided fine-needle biopsy (FNB). The diagnostic utility of this ...needle for differentiating solid pancreatic masses is currently unknown. The aim of this study was to compare the diagnostic performance and yield for tissue acquisition from solid pancreatic lesions of the opposing bevel needle with those of a reverse bevel EUS-FNB needle. Methods Consecutive patients with solid pancreatic masses undergoing EUS-FNB using the opposing bevel (n = 101) and the reverse bevel (n = 100) core biopsy needles were included in the study. Final diagnosis was based on positive histology or at least 12 months of follow-up in cases with a negative biopsy. The primary outcome was the diagnostic performance of the 2 needles for malignant pancreatic masses. A secondary outcome was the diagnostic yield. Results Compared with the reverse bevel needle, using strict criteria the opposing bevel needle provided significantly higher sensitivity (71.1% vs 90.1%; P = .0006) and overall accuracy (74% vs 92%; I = 0.0006) for discriminating malignant from benign solid pancreatic masses. The proportion of samples classified as adequate for histologic analysis was 87% for the reverse bevel needle versus 99% for the opposing bevel needle ( p = 0.002) Multivariate analysis controlling the needle gauge and site did not show any significant difference in accuracy and sensitivity between the 2 groups. There were no adverse events in either group. Conclusions In this first, large, single-center preliminary cohort study, an EUS core biopsy needle with a novel tip, opposing bevel, and sheath design afforded substantially superior tissue yield and diagnostic performance compared with a reverse-bevel needle. If replicated by randomized controlled trials, our findings suggest that similarly designed needles could become the standard of care for EUS-guided tissue acquisition from solid pancreatic masses.
Abstract
Background
A novel fork-tip fine-needle biopsy (FNB) needle has recently been introduced for endoscopic ultrasound (EUS)-guided sampling. The aim of this study was to compare the performance ...of fork-tip FNB histology and standard fine-needle aspiration (FNA) cytology in the diagnosis of solid pancreatic masses.
Methods
A randomized crossover study was performed in patients referred for EUS-guided sampling. Three passes were taken with each needle in a randomized order. Only samples reported as diagnostic of malignancy were considered positive. The primary end point was the sensitivity of diagnosis of malignancy. Secondary end points included the amount of sample obtained, ease of diagnosis, duration of tissue sampling, pathologist viewing time, and cost.
Results
108 patients were recruited. Median age was 69 years (range 30 – 87) and 57 were male; 85.2 % had a final diagnosis of malignancy. There were statistically significant differences in sensitivity (82 % 95 % confidence interval (CI) 72 % to 89 % vs. 71 % 95 %CI 60 % to 80 %), accuracy (84 % 95 %CI 76 % to 91 % vs. 75 % 95 %CI 66 % to 83 %), proportion graded as a straightforward diagnosis (69 % 95 %CI 60 % to 78 % vs. 51 % 95 %CI 41 % to 61 %), and median pathology viewing time (188 vs. 332 seconds) (
P
< 0.001) between FNB and FNA needles, respectively. There was no significant difference in cost between an FNB or FNA strategy.
Conclusion
The diagnostic performance of the fork-tip FNB needle was significantly better than that of FNA; it was associated with ease of diagnosis, shorter pathological viewing times, and was cost neutral.
Background Recent data suggest that quantitative EUS elastography, a novel technique that allows real-time quantification of tissue stiffness, can accurately differentiate malignant from benign solid ...pancreatic masses. Objective To externally validate the diagnostic utility of this technique in an independent cohort. Design and Setting Prospective, single-center study. Patients, Interventions, and Methods A total of 104 patients with evidence of a solid pancreatic mass on cross-sectional imaging and/or endosonography underwent 111 quantitative EUS elastography procedures. Multiple elastographic measurements of the mass lesion and soft-tissue reference areas were undertaken, and the corresponding strain ratios (SRs) were calculated. The final diagnosis was based on pancreatic cytology or histology. Main Outcome Measurements The area under the receiver-operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of quantitative EUS elastography for discriminating malignant from benign pancreatic masses. Results The final diagnoses were primary pancreatic carcinoma (71.2%), neuroendocrine tumor (10.6%), metastatic cancer (1.9%), and pancreatitis (16.3%). Malignant masses had a higher SR ( P = .01) and lower mass elasticity ( P = .003) than inflammatory ones. The areas under the receiver-operating characteristic curve for the detection of pancreatic malignancy of both SR and mass elasticity (0.69 and 0.72, respectively) were less favorable than reported recently. At the cut points providing the highest accuracy in this cohort (4.65 for SR and 0.27% for mass elasticity), quantitative EUS elastography had a sensitivity of 100.0% and 95.7%, specificity of 16.7% and 22.2%, positive predictive value of 86.1% and 86.4%, negative predictive value of 100.0% and 50.0%, and overall accuracy of 86.5% and 83.8%, respectively. Limitations Relatively small number of patients with benign disease. Conclusion In the largest single-center study to date, the diagnostic utility of quantitative EUS elastography for discriminating pancreatic masses was modest, suggesting that it may only supplement rather than supplant the role of pancreatic tissue sampling in the future.
Main recommendations
1
ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely. Strong recommendation, low ...quality evidence.
2
ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.
Strong recommendation, low quality evidence.
3
ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.
Strong recommendation, moderate quality evidence.
4
ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.
Strong recommendation, low quality evidence.
5
ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.
Weak recommendation, low quality evidence.
6
ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas. Strong recommendation, moderate quality evidence.
7
ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.
Strong recommendation, low quality evidence.
8
ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.
Strong recommendation, low quality evidence.
9
ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result.
Strong recommendation, low quality evidence.
The basal-like molecular subtype of pancreatic ductal adenocarcinoma (PDAC) is associated with poor prognosis and upregulation in TP63ΔN (p40) network. Adenosquamous histology can be observed. This ...study assessed immunohistochemical p40 expression in fine needle biopsy (FNB) samples with PDAC and association with cytomorphological features of squamous differentiation and clinical data. 106 EUS FNBs with PDAC were assessed for eight cytomorphological features of squamous differentiation. P40 H-score (intensity 0-3 × percentage positive nuclei) was analysed for association with morphological features, patient age, gender, operability, chemotherapy and survival. P40 H-score in 14 paired FNBs and resections was compared. P40 h-score was 1-3 in 31%, 4-30 in 16% and > 30 in 13% of FNBs. It was significantly associated with intercellular bridges, elongated cell shape, sharp cell borders, angular nuclei with homogenous chromatin (p < 0.001) and dense cytoplasm (p = 0.002). Keratinisation was not seen. Inoperable patients (n = 81) had a shorter median survival for h-score > 30 (n = 9, 1.8 months) than for h-score ≤ 30 (n = 66, 6.7 months) not quite reaching statistical significance (p = 0.08). P40 was significantly associated with squamous morphology in FNBs with PDAC. P40 H-score > 30 showed a trend towards shorter survival in inoperable patients. Squamous differentiation may be a treatment target in PDAC.
EUS-guided choledochoduodenostomy (EUS-CDD) with an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) has emerged as a viable method of establishing biliary drainage in patients with ...malignant distal biliary obstruction (MDBO). Our aim was to assess the efficacy, safety, and outcomes in patients with MDBO who underwent EUS-CDD with an EC-LAMS.
A retrospective review of consecutive patients with MDBO who underwent EUS-CDD with EC-LAMSs at 8 tertiary institutions across the United Kingdom and Ireland between September 2016 and November 2020 was undertaken.
One hundred twenty patients (55% men) with a median age of 73 years (interquartile range, 17; range, 43-94) were included. The median follow-up period in 117 patients was 70 days (interquartile range, 169; range, 3-869), and 23 patients (19.2%) were alive at the end of the follow-up. Three patients were lost to follow-up. Technical success was achieved in 109 patients (90.8%). Clinical success (reduction of serum bilirubin to ≤50% of original value within 14 days) was achieved in 94.8% of patients (92/97). The adverse event rate was 17.5% (n = 21). Biliary reintervention after initial technical success was required in 9 patients (8.3%).
EUS-CDD with EC-LAMSs at tertiary institutions within a regional hepatopancreatobiliary network for treatment of MDBO was effective in those where ERCP was not possible or was unsuccessful. When technical failures or adverse events occur, most patients can be managed with conservative or endoscopic therapy.
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary ...drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage.
A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events.
Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78-90%, I
: 0%). The pooled rate of adverse events (95% CI) was 13% (7-19%, I
: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression.
This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures.
Background
The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown.
Objective
The present systematic review and meta-analysis aims to compare the efficacy of ...different analgesic modalities trialled in AP.
Methods
A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2.
Results
Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting.
Conclusions
There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.
Abstract
Background and study aims
Pancreatic neuroendocrine tumors (PanNETs) outcomes are dependent upon grading by Ki67. This study compared endoscopic ultrasound-guided fine-needle biopsy ...(EUS-FNB) to fine-needle aspiration (FNA) in assessing PanNETs.
Patients and methods
All pancreatic histology for PanNET between January 2009 and June 2017 was included if EUS sampling was performed prior to surgical resection. Ki67 and grade from FNA and FNB samples was compared to surgical histology using correlation coefficient and kappa values. Subgroup analysis was performed for purely solid lesions, lesions < 2 cm and FNB needle type.
Results
One hundred sixity-four patients had PanNET of which 57 underwent surgical resection. Thirty-five lesions underwent FNA and 26 FNB (4 had both) confirming PanNET. 23/ of 35 FNA samples reported Ki67/grading compared to all 26 FNB samples (
P
= 0.0006). Compared to surgical histology, Ki67 on FNA correlated poorly overall (r = –0.08), in solid lesions (r = –0.102) and lesions < 2 cm (r = –0.149) whereas FNB correlated moderately overall (r = 0.65), in solid lesions (r = 0.64) and lesions < 2 cm (r = 0.61). Tumor grade showed poor agreement (kappa) with FNA overall (0.026), in solid lesions (0.044) and lesions < 2 cm (0.00) whereas FNB showed moderate-good agreement overall (0.474), in solid lesions (0.58) and lesions < 2 cm (0.745). Fork-tip FNB needles Ki67 showed strong correlation with surgical histology (r = 0.788) compared to reverse bevel FNB needles (r = 0.521). Both FNB needles showed moderate agreement with tumor grade.
Conclusion
FNB samples were significantly more likely than FNA to provide adequate material for Ki67/grading and showed a closer match to surgical histology. FNB needle types require prospective investigation.
Digital single-operator cholangioscopy (d-SOC) with cholangioscopic biopsy sampling has shown promise in the evaluation of indeterminate biliary strictures. Some studies have suggested higher ...sensitivity for visual impression compared with biopsy sampling, although assessors were not blinded to previous investigations. We aimed to investigate the diagnostic accuracy and interobserver agreement (IOA) of d-SOC in the visual appraisal of biliary strictures when blinded to additional information.
A multicenter, international cohort study was performed. Cholangioscopic videos in patients with a known final diagnosis were systematically scored. Pseudonymized videos were reviewed by 19 experts in 2 steps: blinded for patient history and investigations and unblinded.
Forty-four high-quality videos were reviewed of 19 benign and 25 malignant strictures. The sensitivity and specificity for the diagnosis of malignancy was 74.2% and 46.9% (blinded) and 72.7% and 62.5% (unblinded). Cholangioscopic certainty of a malignant diagnosis led to overdiagnosis (sensitivity, 90.6%; specificity, 33%), especially if no additional information was provided. The IOA for the presence of malignancy was fair for both assessments (Fleiss’ κ = .245 blinded and κ = .321 unblended). For individual visual features, the IOA ranged from slight to moderate for both assessments (κ = .059-.400 vs κ = .031-.452).
This study showed low sensitivity and specificity for blinded and unblinded d-SOC video appraisal of indeterminate biliary strictures, with considerable interobserver variation. Although reaching a consensus on the optical features of biliary strictures remains important, optimizing visually directed biopsy sampling may be the most important role of cholangioscopy in biliary stricture assessment.
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