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CME Activity
CME ACTIVITY
Continuing Medical Education Exam: April 2006 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie016
Expiration date: September 30, 2006
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
Predicting the outcome of UGI hemorrhage Question 1: A 72-year-old man with osteoarthritis who is on NSAIDs presents with hematemesis. He has no other medical problems, his systolic blood pressure is 95 mm Hg, and his hemoglobin is 11.2 g/dL. After fluid resuscitation, endoscopy demonstrates a 1.5-cm ulcer in the distal antrum with a nonbleeding visible vessel, which is treated with a combination of epinephrine injection and cauterization. You recommend admission to the hospital and initiation of oral proton pump inhibitors. Which of the following is true?
Possible answers (A-E) A. Despite endoscopic therapy, the patient’s mortality is near 30%. B. The Rockall score accurately predicts this patient’s mortality risk. C. The Rockall score accurately predicts this patient’s risk for rebleeding. D. Admission of this patient is not necessary because both his mortality and risk for rebleeding are quite low. E. Intravenous PPI therapy is more effective than oral therapy in this patient.
Look-up: Church NI, Dallal HJ, Masson J, et al.Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointest Endosc 2006;63:606-12.
676 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
CME Exam
Backup gear for EMR! Question 2: A 65-year-old woman with persistent dyspepsia undergoes endoscopic mucosal resection of an early gastric cancer. The final image after successful resection of cancer is shown in Figure 1. Which of the following is the most appropriate management of this patient at this stage?
Possible answers (A-D) A. Admit the patient for total gastrectomy because the cancer appears invasive. B. Reschedule the patient for endoscopy to complete the resection because the margins are not free of tumor. C. Schedule the patient for laparoscopic gastric wedge resection and staging. D. Perform an endoclip application to close the defect.
Figure 1. After successful resection of cancer.
Look up: Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601.
Endoscopic drainage of pancreatic fluid collections Question 3: Endoscopic cystogastrostomy of a pancreatic pseudocyst is requested on a 65-year-old woman who is readmitted to the hospital with fever and abdominal pain 4 weeks after an attack of severe pancreatitis. Emergent CT-guided aspiration and Gram stain of the fluid is negative for bacteria. After reviewing the abdominal CT scan (Fig. 2), you discuss the case and management. Which of the following is a false statement about the endoscopic approach to this patient?
Possible answers (A-D) A. The collection is likely to be an organized pancreatic necrosis instead of a pseudocyst. B. Endoscopic therapy can be delayed until the process is organized. C. Transmural drainage is likely to be more effective than transpapillary drainage. D. EUS-guided transmural drainage is safer than non-EUS guided drainage.
Figure 2. Abdominal CT scan.
Look up: Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006;63:635-43.
www.giejournal.org
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 677
CME Exam
EUS-FNAC of a pancreatic mass: any concerns? Question 4:
Possible answers (A-E)
A 74-year-old woman presents with upper abdominal pain and 20-pound weight loss. CT scan reveals a low-density mass in the pancreatic head, without ascites or liver metastasis. She undergoes EUS followed by EUS-guided fine-needle aspiration cytology (FNAC) to establish the diagnosis (Video 1, available at www.giejournal.org). Which of the following is true about EUS and EUSguided FNAC of a pancreatic head mass?
A. The risk of pancreatitis following the procedure is low (~1%). B. The risk of pancreatitis following the procedure is high (~10%). C. ERCP has a higher diagnostic yield when compared to the EUS-guided FNAC. D. ERCP has a similar complication risk when compared to the EUS-guided FNAC. E. Lack of biliary obstruction by EUS excludes malignancy in pancreatic head masses.
Look up: Eloubeidi MA, Tamhane A, Varadarajulu S, et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622-29.
678 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: April 2006 QUESTION 1: CORRECT RESPONSE: B Rationale for correct response: The Rockall scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), endoscopic diagnosis (0-2), and endoscopic stigmata of recent hemorrhage (0-2), with a maximum possible score of 11, was developed as a simple tool to predict mortality in a large (n = 2531) prospective cohort study of unselected patients with upper GI hemorrhage admitted to hospitals in England during 1993.1,2 Subsequent studies demonstrated the scoring system’s usefulness in identifying the low-risk patients (score %2) who might be eligible for early discharge or out-patient management.3 Our patient has a Rockall score of 6. Church et al attempt to validate the use of the Rockall scoring system in triaging a selected group of patients presenting with significant upper GI hemorrhage (score R3) who require endoscopic therapy.4 Despite data suggesting that the risk for rebleeding increases with an increasing Rockall score, the scoring system does not appear to be an accurate predictor of rebleeding, with the best sensitivity/specificity measured at 69% and 53%, respectively, when a cutoff score of 6 was used.5 In this same cohort, however, it was found that a Rockall score of >6 was an adequate predictor of increased risk for mortality, with a sensitivity and specificity of 82% and 69%, respectively. Additionally, a score of %5 demonstrated no increased risk for mortality. Calculation of a Rockall score may be useful to predict which patients will do poorly, and this could be used to facilitate decisions concerning postendoscopy decisions regarding placement and monitoring of patients. REFERENCES: 1. Rockall TA, Logan RFA, Devlin HB, et al. Variation in outcome after acute upper gastrointestinal haemorrhage. Lancet 1995;346:346-50. 2. Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-21. 3. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996;347:1138-40. 4. Church NI, Dallal HJ, Masson J, et al.Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointest Endosc 2006;63:606-12. 5. Dulai GS. Rockall redux: retracted or redacted? Gastrointest Endosc 2006;63:613-14.
QUESTION 2: CORRECT RESPONSE: D Rationale for correct response: This is a classic image of a gastric perforation after endoscopic mucosal resection. Endoluminal closure of such perforations is certainly feasible currently.1-3 Endoscopic closure of an iatrogenic perforation with endoclips was first described by Binmoeller et al1 in 1993. Subsequent reports confirmed that a small perforation can be closed with clips, while a large defect requires repair using a combination of an omental patch drawn into the stomach followed by closure with clips.2,3 In a large study of 121 gastric perforations in 2460 patients who had undergone gastric EMR at the National Cancer Center Hospital (1987-2004), the first 4 patients were treated with emergent surgery and the subsequent 117 patients underwent clip closure. Endoscopic clip closure was successful in 98% of patients, and the recovery rate of these patients was similar to those without perforation.4 Expertise in the use of clips is critical for any endoscopist undertaking endoscopic resection of cancers so that the perforations can be managed successfully without the need for surgery.5 REFERENCES: 1. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172-4. 2. Hashiba K, Carvalho AM, Diniz G, et al. Experimental endoscopic repair of gastric perforations with an omental patch and clips. Gastrointest Endosc 2001;54:500-4.
www.giejournal.org
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 679
CME Answers 3. Tsunada S, Ogata S, Ohyama T, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51. 4. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601. 5. Raju GS.“Hello, Mr. Clips—Could you chip in please?” Gastroenterology 2003;125:1896-97.
QUESTION 3: CORRECT RESPONSE: D Rationale for correct response: This case represents a typical patient with organized pancreatic necrosis.1 Although many collections that occur as a complication of pancreatitis are labeled as pancreatic pseudocysts (as in this case), they may represent other types of collections. The fact that the patient had a severe episode of pancreatitis suggests that underlying pancreatic necrosis was present at the onset and is likely to be present now within the collection. Patients with an organized pancreatic necrosis may be observed if the collection remains sterile. Intervention is recommended if the fluid is infected. Organized pancreatic necrosis is difficult to resolve with transpapillary drainage because the evacuation of solid debris through relatively small pancreatic ducts is not possible. The success rate for endoscopic drainage in patients with organized pancreatic necrosis is significantly lower than that for pancreatic pseudocysts arising as a complication of chronic pancreatitis.1-3 Despite the belief by many experts that EUS-guided transmural drainage is safer than non-EUS guided drainage, this has not been proven.4 REFERENCES: 1. Baron TH. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am 2003;13:743-64. 2. Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56:7-17. 3. Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006;63:635-43. 4. Farrell JJ. Endoscopic therapy for pancreatic-fluid collections: lessons for success? Gastrointest Endosc 2006;63:644-7.
QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: EUS-guided FNAC of the pancreatic head mass is safe, and the risk of pancreatitis after EUS-guided FNAC of a pancreatic head mass is low (~1%). In a prospective cohort study of 355 consecutive patients with a solid pancreatic mass who underwent EUS-guided FNAC at a tertiary referral center, major complications were encountered in 9 patients (2.54%) and hospitalization was required in 5 patients (2%). Of the 3 patients with a post–EUS-FNAC pancreatitis, 1 patient required surgical debridement of pancreatic necrosis. None of the patients experienced significant bleeding, perforation, or death.1 This study confirms the earlier observation from a multicenter retrospective study that EUS-guided FNAC of a pancreatic mass is associated with a low complication rate.2 Because of a low diagnostic yield (47% vs 94%) and a high risk of pancreatitis (33% vs 0%) with the ERCP compared to the EUS-guided FNAC, gastroenterologists should prefer EUS-guided FNAC instead of ERCP when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction or cholangitis.3 REFERENCES: 1. Eloubeidi MA, Tamhane A, Varadarajulu S, et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622-9. 2. Eloubeidi MA, Gress FG, Savides TJ, et al. Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004;60:385-9. 3. Wakatsuki T, Irisawa A, Bhutani MS, et al. Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fineneedle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture. J Gastroenterol Hepatol 2005;20:1707-11.
680 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
Continuing Medical Education Exam: April 2006 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie016
Expiration date: September 30, 2006
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
Predicting the outcome of UGI hemorrhage Question 1: A 72-year-old man with osteoarthritis who is on NSAIDs presents with hematemesis. He has no other medical problems, his systolic blood pressure is 95 mm Hg, and his hemoglobin is 11.2 g/dL. After fluid resuscitation, endoscopy demonstrates a 1.5-cm ulcer in the distal antrum with a nonbleeding visible vessel, which is treated with a combination of epinephrine injection and cauterization. You recommend admission to the hospital and initiation of oral proton pump inhibitors. Which of the following is true?
Possible answers (A-E) A. Despite endoscopic therapy, the patient’s mortality is near 30%. B. The Rockall score accurately predicts this patient’s mortality risk. C. The Rockall score accurately predicts this patient’s risk for rebleeding. D. Admission of this patient is not necessary because both his mortality and risk for rebleeding are quite low. E. Intravenous PPI therapy is more effective than oral therapy in this patient.
Look-up: Church NI, Dallal HJ, Masson J, et al.Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointest Endosc 2006;63:606-12.
676 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
CME Exam
Backup gear for EMR! Question 2: A 65-year-old woman with persistent dyspepsia undergoes endoscopic mucosal resection of an early gastric cancer. The final image after successful resection of cancer is shown in Figure 1. Which of the following is the most appropriate management of this patient at this stage?
Possible answers (A-D) A. Admit the patient for total gastrectomy because the cancer appears invasive. B. Reschedule the patient for endoscopy to complete the resection because the margins are not free of tumor. C. Schedule the patient for laparoscopic gastric wedge resection and staging. D. Perform an endoclip application to close the defect.
Figure 1. After successful resection of cancer.
Look up: Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601.
Endoscopic drainage of pancreatic fluid collections Question 3: Endoscopic cystogastrostomy of a pancreatic pseudocyst is requested on a 65-year-old woman who is readmitted to the hospital with fever and abdominal pain 4 weeks after an attack of severe pancreatitis. Emergent CT-guided aspiration and Gram stain of the fluid is negative for bacteria. After reviewing the abdominal CT scan (Fig. 2), you discuss the case and management. Which of the following is a false statement about the endoscopic approach to this patient?
Possible answers (A-D) A. The collection is likely to be an organized pancreatic necrosis instead of a pseudocyst. B. Endoscopic therapy can be delayed until the process is organized. C. Transmural drainage is likely to be more effective than transpapillary drainage. D. EUS-guided transmural drainage is safer than non-EUS guided drainage.
Figure 2. Abdominal CT scan.
Look up: Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006;63:635-43.
www.giejournal.org
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 677
CME Exam
EUS-FNAC of a pancreatic mass: any concerns? Question 4:
Possible answers (A-E)
A 74-year-old woman presents with upper abdominal pain and 20-pound weight loss. CT scan reveals a low-density mass in the pancreatic head, without ascites or liver metastasis. She undergoes EUS followed by EUS-guided fine-needle aspiration cytology (FNAC) to establish the diagnosis (Video 1, available at www.giejournal.org). Which of the following is true about EUS and EUSguided FNAC of a pancreatic head mass?
A. The risk of pancreatitis following the procedure is low (~1%). B. The risk of pancreatitis following the procedure is high (~10%). C. ERCP has a higher diagnostic yield when compared to the EUS-guided FNAC. D. ERCP has a similar complication risk when compared to the EUS-guided FNAC. E. Lack of biliary obstruction by EUS excludes malignancy in pancreatic head masses.
Look up: Eloubeidi MA, Tamhane A, Varadarajulu S, et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622-29.
678 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: April 2006 QUESTION 1: CORRECT RESPONSE: B Rationale for correct response: The Rockall scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), endoscopic diagnosis (0-2), and endoscopic stigmata of recent hemorrhage (0-2), with a maximum possible score of 11, was developed as a simple tool to predict mortality in a large (n = 2531) prospective cohort study of unselected patients with upper GI hemorrhage admitted to hospitals in England during 1993.1,2 Subsequent studies demonstrated the scoring system’s usefulness in identifying the low-risk patients (score %2) who might be eligible for early discharge or out-patient management.3 Our patient has a Rockall score of 6. Church et al attempt to validate the use of the Rockall scoring system in triaging a selected group of patients presenting with significant upper GI hemorrhage (score R3) who require endoscopic therapy.4 Despite data suggesting that the risk for rebleeding increases with an increasing Rockall score, the scoring system does not appear to be an accurate predictor of rebleeding, with the best sensitivity/specificity measured at 69% and 53%, respectively, when a cutoff score of 6 was used.5 In this same cohort, however, it was found that a Rockall score of >6 was an adequate predictor of increased risk for mortality, with a sensitivity and specificity of 82% and 69%, respectively. Additionally, a score of %5 demonstrated no increased risk for mortality. Calculation of a Rockall score may be useful to predict which patients will do poorly, and this could be used to facilitate decisions concerning postendoscopy decisions regarding placement and monitoring of patients. REFERENCES: 1. Rockall TA, Logan RFA, Devlin HB, et al. Variation in outcome after acute upper gastrointestinal haemorrhage. Lancet 1995;346:346-50. 2. Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-21. 3. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996;347:1138-40. 4. Church NI, Dallal HJ, Masson J, et al.Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointest Endosc 2006;63:606-12. 5. Dulai GS. Rockall redux: retracted or redacted? Gastrointest Endosc 2006;63:613-14.
QUESTION 2: CORRECT RESPONSE: D Rationale for correct response: This is a classic image of a gastric perforation after endoscopic mucosal resection. Endoluminal closure of such perforations is certainly feasible currently.1-3 Endoscopic closure of an iatrogenic perforation with endoclips was first described by Binmoeller et al1 in 1993. Subsequent reports confirmed that a small perforation can be closed with clips, while a large defect requires repair using a combination of an omental patch drawn into the stomach followed by closure with clips.2,3 In a large study of 121 gastric perforations in 2460 patients who had undergone gastric EMR at the National Cancer Center Hospital (1987-2004), the first 4 patients were treated with emergent surgery and the subsequent 117 patients underwent clip closure. Endoscopic clip closure was successful in 98% of patients, and the recovery rate of these patients was similar to those without perforation.4 Expertise in the use of clips is critical for any endoscopist undertaking endoscopic resection of cancers so that the perforations can be managed successfully without the need for surgery.5 REFERENCES: 1. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172-4. 2. Hashiba K, Carvalho AM, Diniz G, et al. Experimental endoscopic repair of gastric perforations with an omental patch and clips. Gastrointest Endosc 2001;54:500-4.
www.giejournal.org
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 679
CME Answers 3. Tsunada S, Ogata S, Ohyama T, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51. 4. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601. 5. Raju GS.“Hello, Mr. Clips—Could you chip in please?” Gastroenterology 2003;125:1896-97.
QUESTION 3: CORRECT RESPONSE: D Rationale for correct response: This case represents a typical patient with organized pancreatic necrosis.1 Although many collections that occur as a complication of pancreatitis are labeled as pancreatic pseudocysts (as in this case), they may represent other types of collections. The fact that the patient had a severe episode of pancreatitis suggests that underlying pancreatic necrosis was present at the onset and is likely to be present now within the collection. Patients with an organized pancreatic necrosis may be observed if the collection remains sterile. Intervention is recommended if the fluid is infected. Organized pancreatic necrosis is difficult to resolve with transpapillary drainage because the evacuation of solid debris through relatively small pancreatic ducts is not possible. The success rate for endoscopic drainage in patients with organized pancreatic necrosis is significantly lower than that for pancreatic pseudocysts arising as a complication of chronic pancreatitis.1-3 Despite the belief by many experts that EUS-guided transmural drainage is safer than non-EUS guided drainage, this has not been proven.4 REFERENCES: 1. Baron TH. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am 2003;13:743-64. 2. Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002;56:7-17. 3. Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006;63:635-43. 4. Farrell JJ. Endoscopic therapy for pancreatic-fluid collections: lessons for success? Gastrointest Endosc 2006;63:644-7.
QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: EUS-guided FNAC of the pancreatic head mass is safe, and the risk of pancreatitis after EUS-guided FNAC of a pancreatic head mass is low (~1%). In a prospective cohort study of 355 consecutive patients with a solid pancreatic mass who underwent EUS-guided FNAC at a tertiary referral center, major complications were encountered in 9 patients (2.54%) and hospitalization was required in 5 patients (2%). Of the 3 patients with a post–EUS-FNAC pancreatitis, 1 patient required surgical debridement of pancreatic necrosis. None of the patients experienced significant bleeding, perforation, or death.1 This study confirms the earlier observation from a multicenter retrospective study that EUS-guided FNAC of a pancreatic mass is associated with a low complication rate.2 Because of a low diagnostic yield (47% vs 94%) and a high risk of pancreatitis (33% vs 0%) with the ERCP compared to the EUS-guided FNAC, gastroenterologists should prefer EUS-guided FNAC instead of ERCP when a cytological diagnosis of a pancreatic mass is required, especially when there is no biliary obstruction or cholangitis.3 REFERENCES: 1. Eloubeidi MA, Tamhane A, Varadarajulu S, et al. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006;63:622-9. 2. Eloubeidi MA, Gress FG, Savides TJ, et al. Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004;60:385-9. 3. Wakatsuki T, Irisawa A, Bhutani MS, et al. Comparative study of diagnostic value of cytologic sampling by endoscopic ultrasonography-guided fineneedle aspiration and that by endoscopic retrograde pancreatography for the management of pancreatic mass without biliary stricture. J Gastroenterol Hepatol 2005;20:1707-11.
680 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org