Background and Aims Insulinomas are one of the most common functional pancreatic neuroendocrine tumors. Surgical removal is the standard of care. Patients unfit for or refusing surgery need an ...alternative nonsurgical method to alleviate symptoms. EUS has been used to localize, aspirate, and tattoo insulinomas and to inject alcohol for local ablation. This study is aimed at assessing the feasibility of EUS-guided radiofrequency ablation (EUS-RFA) for managing patients with a symptomatic insulinoma by using a novel EUS-RFA needle electrode. Methods The EUS-RFA system used consists of a prototype 19-gauge needle electrode, generator, and internal cooling system. EUS-guided RFA is performed under real-time visualization at 50 W to ablate pancreatic insulinomas. Results In this observational human case series from a tertiary care center, 3 patients with a symptomatic pancreatic insulinoma, not eligible for surgery, underwent EUS-RFA by using an internally cooled prototype needle electrode. All had rapid symptom relief with biochemical improvement and remained symptom free at 11 to 12 months of follow-up. There were no procedure-related adverse events. Conclusions EUS-RFA with the novel device can be considered in select patients with a symptomatic pancreatic insulinoma based on preliminary findings of a beneficial effect without adverse events. Assessment of the safety profile requires larger prospective trials.
Background and Aims EUS-guided drainage using plastic stents may be inadequate for treatment of walled-off necrosis (WON). Recent studies report variable outcomes even when using covered metal ...stents. The aim of this study was to evaluate the efficacy of a dedicated covered biflanged metal stent (BFMS) when adopting an endoscopic “step-up approach” for drainage of symptomatic WON. Methods We retrospectively evaluated consecutive patients with symptomatic WON who underwent EUS-guided drainage using BFMSs over a 3-year period. Reassessment was done between 48 and 72 hours for resolution. Endoscopic reinterventions were tailored in nonresponders in a stepwise manner. Step 1 encompassed declogging the blocked lumen of the BFMS. In step 2, a nasocystic tube was placed via BFMSs with intermittent irrigation. Step 3 involved direct endoscopic necrosectomy (DEN). BFMSs were removed between 4 and 8 weeks of follow-up. The main outcome measures were technical success, clinical success, adverse events, and need for DEN. Results Two hundred five WON patients underwent EUS-guided drainage using BFMSs. Technical success was achieved in 203 patients (99%). Periprocedure adverse events occurred in 8 patients (bleeding in 6, perforation in 2). Clinical success with BFMSs alone was seen in 153 patients (74.6%). Reintervention adopting the step-up approach was required in 49 patients (23.9%). Incremental success was achieved in 10 patients with step 1, 16 patients with step 2, and 19 patients with step 3. Overall clinical success was achieved in 198 patients (96.5%), with DEN required in 9.2%. Four patients failed treatment and required surgery (2) or percutaneous drainage (2). Conclusions The endoscopic step-up approach using BFMSs was safe, effective, and yielded successful outcomes in most patients, reducing the need for DEN.
Background Long-term results of extracorporeal shockwave lithotripsy (ESWL) for large pancreatic duct (PD) stones in patients with idiopathic calcific pancreatitis (CP) are scanty. Objective To ...evaluate intermediate and long-term results of ESWL in a large cohort of patients with idiopathic CP. Design Cross-sectional study; retrospective chart review. Setting A high-volume, tertiary-care center for endoscopy and GI diseases. Patients A total of 636 patients with idiopathic CP who underwent ESWL and ERCP were followed-up. Patients were divided into intermediate (24-60 months) and long-term (>60 months) follow-up groups. Intervention ESWL and ERCP. Main Outcome Measurements Improvement in pain, analgesic use, hospitalization for pain, recurrence of calculi, need for additional intervention, and quality of life. Results A total of 636 of 1006 patients who underwent ESWL between 2004 and 2009 were followed for a maximum of 96 months. There were 364 patients in the intermediate follow-up group and 272 in the long-term follow-up group. After ESWL and ERCP, absence of pain was seen in 250 patients (68.7%), mild-to-moderate pain in 94 patients (25.4%), and severe pain in 20 patients (5.5%) of the intermediate group. In the long-term group, 164 patients (60.3%) had no pain, 97 patients (35.7%) had mild or moderate episodes of pain, whereas 11 patients (4.04%) had episodic severe pain. Recurrence of calculi was seen in 51 patients (14.01%) in the intermediate follow-up group and in 62 patients (22.8%) in the long-term group. Quality of life improved in a significant number of patients in both groups. Limitations Retrospective study, single center, recall bias, and subjective pain and quality-of-life measurement scale. Conclusion ESWL for large PD calculi offers good results in patients of idiopathic CP on intermediate and long-term follow-up.
Background Currently available techniques to diagnose indeterminate biliary lesions have many limitations. Objective To assess the accuracy of single-operator peroral cholangioscopy by using the ...SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions. Design Prospective, single-arm, single-center study. Setting Tertiary referral center. Patients Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling. Interventions SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies. Main Outcome Measurements Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions. Results Thirty-six patients (22 men, mean age 48.3 years range 27-68 years) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis. Limitations No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures. Conclusions SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.