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Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis
Abstracts
Sa1504 Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy (EUS-FNAB) Using a Novel 25-Gauge Core Biopsy Needle: Optimizing the Yield of Both Cytology and Histology Takuji Iwashita*, Yousuke Nakai, Jason B. Samarasena, Do Hyun Park, John G. Lee, Kenneth J. Chang H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, Orange, CA
Post necropsy gross specimen showing complete fistula formation between CBD and duodenum.
Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis Sheba Vohra*1, Edward W. Holt2, Yasser M. Bhat3, Janak N. Shah3, Steve Kane3, Kenneth F. Binmoeller3 1 Internal Medicine, California Pacific Medical Center, San Francisco, CA; 2Gastroenterology, California Pacific Medical Center, San Francisco, CA; 3Interventional Endoscopy Service, California Pacific Medical Center, San Francisco, CA Background: ERCP is routinely used to evaluate and treat suspected choledocholithiasis (CDL). However, in the pregnant patient, radiation exposure during ERCP poses a risk to the fetus. Endoscopic ultrasound (EUS) is highly sensitive in the detection of CDL, and is able to determine the size and number of stones. We evaluated the utility of EUS prior to ERCP in pregnant patients with suspected CDL. Aim: To determine if same-session EUS-based ERCP in pregnant patients with suspected CDL is associated with a reduction in ERCPrelated complications. Methods: We retrospectively identified pregnant patients referred to our center for suspected CDL between 2008 and 2011. EUS, using a curved linear array echoendoscope, was performed in all patients to confirm CDL and to determine the size and number of stones. Patients with confirmed CDL underwent ERCP, without fluoroscopy when possible. Deep selective bile duct cannulation was confirmed by aspiration of yellow bile and stone extraction was accomplished after sphincterotomy was performed. The number of extracted stones was counted and compared to the number of stones identified by EUS. Cholangioscopy was performed at the discretion of the endoscopist to confirm CBD clearance. Patient charts were reviewed to determine indications, procedure times, radiation use, clinical course and complications. Results: Ten pregnant women with suspected CDL were included in the study. The mean age was 30.7 years (range 20-40) and the mean gestation was 24 weeks (range 11-31). All 10 patients were symptomatic (acute abdominal pain ⫽ 10, elevated transaminases ⫽ 9, gallstone pancreatitis ⫽3). Four patients had no evidence of stones at EUS and were managed conservatively with uneventful outcomes. Five patients with CDL and one patient with a pancreatic duct stone at EUS went on to same-session ERCP. In 4 of 5 patients with CDL, the number of stones extracted matched the number of stones seen at EUS. Cholangioscopy was used to clear the common bile duct in the patient with mismatched stone counts. The sixth patient with a pancreatic duct stone underwent stent placement with a 5 French stent. No fluoroscopy was used in 5 patients and a 1-second fluoroscopic image without radiograph was required in the patient with a pancreatic duct stone to confirm wire position prior to stent insertion. The average endoscopy time was 43 minutes for the ERCP group vs. 11 minutes for the EUS group (p ⬍0.01). There were no complications in any of the cases. Conclusion: EUS prior to ERCP eliminated the need for ERCP and its attendant risks in 4 of 10 pregnant patients with suspected CDL. ERCP with stone extraction was successful without the use of fluoroscopy in all patients with bile duct stones. When available, same-session EUS should precede ERCP in the treatment of pregnant patients with suspected CDL.
www.giejournal.org
Background: Novel 19 and 22-gauge core biopsy needles which feature a hollowed-out reverse bevel to trap core are now available. Based on initial publications on the 19-gauge core biopsy needle, the current “best practice” for high core acquisition is to utilize only 3-5 to-and-fro needle movements along with high suction (10cc). A new 25-gauge core biopsy needle (CBN25) has been developed. Whether this same FNAB technique is most effective for CBN25 is unknown. Aim: To determine the optimal FNAB technique to obtain core specimen and increase histological and cytological yields using CBN25. Patients and Methods: CBN25 was used for consecutive patients presenting with a solid lesion for EUS-FNA between May and October 2011. After EUS evaluation, the lesion was punctured using CBN25 with either one of two FNA techniques. In the first 3 months, 3-5 to-and-fro movements with 10cc-syringe suction (ST, standard technique) was used and in the latter 5 months 10-20 to-and-fro movements with minimal negative pressure by pulling the stylet slowly (MT, modified technique) was used. The specimen was expelled onto a glass slide and all visible core were placed in formalin after measurement of core specimen lengths. The remainder of the non-core specimen was submitted for cytology. Per protocol there was a 4-pass stopping rule which was salvaged using a standard 25 gauge FNA needle. Data was analyzed retrospectively. Results: 60 patients (21 female; median age 67.5 (range 35-90)) underwent EUS-FNAB using CBN25 with ST in 20 and MT in 40. Punctured lesions and final diagnoses are summarized in table 1 and 2. FNAB with CBN25 was successful in all cases. Median number of FNAB passes was 4 (range 3-4). A total of 236 passes using CBN25 was performed with ST in 80 passes and MT in 156 passes. The yield of visible core was 24% (19/80) in ST compared to 79% (123/156) in MT (P⬍0.001, t-test). The mean core length was 1.6 mm (SD, 1.7) in ST and 8.0 mm (SD, 9.0) in MT. (P⬍0.001). Among patients with a final diagnosis of a neoplastic lesion (59 patients), the yield of histological diagnosis was 55% (11/20) in ST as compared to 90% (35/39) in MT (P⬍0.01, Chi-squared test). The cytological yield showed a positive diagnosis in 70% (14/20) in ST as compared to 92% (36/39) in MT (P⬍0.05). Overall diagnostic yields were 75% (15/20) and 95% (37/39) in ST and MT, respectively (P⬍0.05). 7 patients had salvage FNA (4 positive, 3 false negative). No complications were seen in any of the patients. Conclusion: After technique modification, EUS-FNAB using CBN25 had a histologic yield of 90% and an overall diagnostic yield of 95%. This needle and technique appear optimum for EUS tissue acquisition. Table 1. Location of solid lesions Punctured lesion (N)
Standard technique
Modified technique
Pancreatic mass Liver mass Enlarged lymph node Submucosal lesion
17 1 1 1
33 3 2 2
Table 2. Final diagnosis of solid lesion. Final diagnosis (N) Adenocarcinoma Neuroendocrine Malignant lymphoma Anaplastic carcinoma GIST Glomus tumor Leiomyoma Metastatic tumor adenocarcinoma hepatoma melanoma neuronedocrine renal cell carcinoma Autoimmune pancreatitis
Volume 75, No. 4S : 2012
Standard technique
Modified technique
14 2 2
24 6 1 1 1
1 1 2 1 1 1 1 1
GASTROINTESTINAL ENDOSCOPY
AB183
Sa1504 Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy (EUS-FNAB) Using a Novel 25-Gauge Core Biopsy Needle: Optimizing the Yield of Both Cytology and Histology Takuji Iwashita*, Yousuke Nakai, Jason B. Samarasena, Do Hyun Park, John G. Lee, Kenneth J. Chang H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, Orange, CA
Post necropsy gross specimen showing complete fistula formation between CBD and duodenum.
Sa1503 EUS-Based ERCP Reduces Risk Exposure in Pregnant Patients With Suspected Choledocholithiasis Sheba Vohra*1, Edward W. Holt2, Yasser M. Bhat3, Janak N. Shah3, Steve Kane3, Kenneth F. Binmoeller3 1 Internal Medicine, California Pacific Medical Center, San Francisco, CA; 2Gastroenterology, California Pacific Medical Center, San Francisco, CA; 3Interventional Endoscopy Service, California Pacific Medical Center, San Francisco, CA Background: ERCP is routinely used to evaluate and treat suspected choledocholithiasis (CDL). However, in the pregnant patient, radiation exposure during ERCP poses a risk to the fetus. Endoscopic ultrasound (EUS) is highly sensitive in the detection of CDL, and is able to determine the size and number of stones. We evaluated the utility of EUS prior to ERCP in pregnant patients with suspected CDL. Aim: To determine if same-session EUS-based ERCP in pregnant patients with suspected CDL is associated with a reduction in ERCPrelated complications. Methods: We retrospectively identified pregnant patients referred to our center for suspected CDL between 2008 and 2011. EUS, using a curved linear array echoendoscope, was performed in all patients to confirm CDL and to determine the size and number of stones. Patients with confirmed CDL underwent ERCP, without fluoroscopy when possible. Deep selective bile duct cannulation was confirmed by aspiration of yellow bile and stone extraction was accomplished after sphincterotomy was performed. The number of extracted stones was counted and compared to the number of stones identified by EUS. Cholangioscopy was performed at the discretion of the endoscopist to confirm CBD clearance. Patient charts were reviewed to determine indications, procedure times, radiation use, clinical course and complications. Results: Ten pregnant women with suspected CDL were included in the study. The mean age was 30.7 years (range 20-40) and the mean gestation was 24 weeks (range 11-31). All 10 patients were symptomatic (acute abdominal pain ⫽ 10, elevated transaminases ⫽ 9, gallstone pancreatitis ⫽3). Four patients had no evidence of stones at EUS and were managed conservatively with uneventful outcomes. Five patients with CDL and one patient with a pancreatic duct stone at EUS went on to same-session ERCP. In 4 of 5 patients with CDL, the number of stones extracted matched the number of stones seen at EUS. Cholangioscopy was used to clear the common bile duct in the patient with mismatched stone counts. The sixth patient with a pancreatic duct stone underwent stent placement with a 5 French stent. No fluoroscopy was used in 5 patients and a 1-second fluoroscopic image without radiograph was required in the patient with a pancreatic duct stone to confirm wire position prior to stent insertion. The average endoscopy time was 43 minutes for the ERCP group vs. 11 minutes for the EUS group (p ⬍0.01). There were no complications in any of the cases. Conclusion: EUS prior to ERCP eliminated the need for ERCP and its attendant risks in 4 of 10 pregnant patients with suspected CDL. ERCP with stone extraction was successful without the use of fluoroscopy in all patients with bile duct stones. When available, same-session EUS should precede ERCP in the treatment of pregnant patients with suspected CDL.
www.giejournal.org
Background: Novel 19 and 22-gauge core biopsy needles which feature a hollowed-out reverse bevel to trap core are now available. Based on initial publications on the 19-gauge core biopsy needle, the current “best practice” for high core acquisition is to utilize only 3-5 to-and-fro needle movements along with high suction (10cc). A new 25-gauge core biopsy needle (CBN25) has been developed. Whether this same FNAB technique is most effective for CBN25 is unknown. Aim: To determine the optimal FNAB technique to obtain core specimen and increase histological and cytological yields using CBN25. Patients and Methods: CBN25 was used for consecutive patients presenting with a solid lesion for EUS-FNA between May and October 2011. After EUS evaluation, the lesion was punctured using CBN25 with either one of two FNA techniques. In the first 3 months, 3-5 to-and-fro movements with 10cc-syringe suction (ST, standard technique) was used and in the latter 5 months 10-20 to-and-fro movements with minimal negative pressure by pulling the stylet slowly (MT, modified technique) was used. The specimen was expelled onto a glass slide and all visible core were placed in formalin after measurement of core specimen lengths. The remainder of the non-core specimen was submitted for cytology. Per protocol there was a 4-pass stopping rule which was salvaged using a standard 25 gauge FNA needle. Data was analyzed retrospectively. Results: 60 patients (21 female; median age 67.5 (range 35-90)) underwent EUS-FNAB using CBN25 with ST in 20 and MT in 40. Punctured lesions and final diagnoses are summarized in table 1 and 2. FNAB with CBN25 was successful in all cases. Median number of FNAB passes was 4 (range 3-4). A total of 236 passes using CBN25 was performed with ST in 80 passes and MT in 156 passes. The yield of visible core was 24% (19/80) in ST compared to 79% (123/156) in MT (P⬍0.001, t-test). The mean core length was 1.6 mm (SD, 1.7) in ST and 8.0 mm (SD, 9.0) in MT. (P⬍0.001). Among patients with a final diagnosis of a neoplastic lesion (59 patients), the yield of histological diagnosis was 55% (11/20) in ST as compared to 90% (35/39) in MT (P⬍0.01, Chi-squared test). The cytological yield showed a positive diagnosis in 70% (14/20) in ST as compared to 92% (36/39) in MT (P⬍0.05). Overall diagnostic yields were 75% (15/20) and 95% (37/39) in ST and MT, respectively (P⬍0.05). 7 patients had salvage FNA (4 positive, 3 false negative). No complications were seen in any of the patients. Conclusion: After technique modification, EUS-FNAB using CBN25 had a histologic yield of 90% and an overall diagnostic yield of 95%. This needle and technique appear optimum for EUS tissue acquisition. Table 1. Location of solid lesions Punctured lesion (N)
Standard technique
Modified technique
Pancreatic mass Liver mass Enlarged lymph node Submucosal lesion
17 1 1 1
33 3 2 2
Table 2. Final diagnosis of solid lesion. Final diagnosis (N) Adenocarcinoma Neuroendocrine Malignant lymphoma Anaplastic carcinoma GIST Glomus tumor Leiomyoma Metastatic tumor adenocarcinoma hepatoma melanoma neuronedocrine renal cell carcinoma Autoimmune pancreatitis
Volume 75, No. 4S : 2012
Standard technique
Modified technique
14 2 2
24 6 1 1 1
1 1 2 1 1 1 1 1
GASTROINTESTINAL ENDOSCOPY
AB183