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Su1987 Pilot Study of a New Platform for Testing EUS-FNA Needles
Abstracts Background: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is commonly used for the diagnosis of various gastrointestinal lesions. Recently, a novel fine needle biopsy (FNB) system (Sharkcore, Medtronic) was developed to acquire cohesive units of tissue to increase the diagnostic yield of EUS. Aims: Our study objective was to compare the diagnostic yield of EUS-FNA using a conventional needle vs. EUS-FNB using the novel needle for gastrointestinal lesions. Methods: We conducted a prospective analysis of patients undergoing diagnostic EUS from November 2014 to October 2015. Each patient underwent 3 FNA passes followed by 3 FNB passes, without on-site cytologic evaluation. Data gathered included demographics, size and location of the lesion, needle size, and complications. Pathology and cytology were reviewed separately by two blinded, expert gastrointestinal pathologists. Diagnostic yield was defined as the ratio between the number of significant findings detected by EUS tissue acquisition and the total number of EUS examinations performed for a given indication. Results: 89 patients were enrolled in the study (MZ41, FZ48, mean age 66 years range 31-88). Indications for EUS: 53% solid pancreatic lesions (N Z 48), 30% gastric submucosal lesions (N Z 26), and 17% enlarged lymph nodes or intra-abdominal/thoracic masses (N Z 15). 22-gauge needles were used in 62 cases (70%) and 25-gauge needles were used in 27 cases (30%). Overall diagnostic yield for 3 needle passes was higher with FNB vs. FNA (76% [N Z 68] vs. 61% [N Z 52], P Z 0.02). In particular, diagnostic yield was higher for FNB vs. FNA for solid pancreatic lesions (85% [N Z 40] vs. 69% [N Z 33], P Z 0.048) and gastric submucosal lesions (78% [N Z 20] vs. 44% [N Z 12], P Z 0.04). Diagnostic yield for lymph nodes or intra-abdominal/thoracic masses (N Z 15) was similar with FNB compared to FNA (60% [N Z 9] vs. 50% [N Z 7], P Z 0.3]. We also evaluated tissue quantity and quality of FNB specimens; mean tissue length was 2.36 1.25 mm with a mean lesional tissue percentage of 75%. One complication occurred (mild acute pancreatitis). Conclusions: FNB using a novel core needle system is safe and effective for diagnosis of a variety of gastrointestinal lesions. When performed without on-site cytologic evaluation, EUS-FNB has a higher diagnostic yield than FNA and may represent an advance for endoscopic ultrasound guided gastrointestinal biopsies.
Su1986 EUS Guided Coiling in Post Cyanoacrylate Gastric Variceal Rebleed Roy J. Mukkada*, Philip Augustine, Abraham Koshy, Antony Chettupuzha, Rajesh Antony, Mathews Chooracken, Jose F. Vadukkoot Gastroenterology, Lakeshore Hospital, Kochi, Kerala, India N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25-50%. Endocoiling is an emerging treatment modality for bleeding gastric varices. We performed endocoiling of varices in 14 patients who re-bled after cyanoacrylate injection. Endocoiling was done under endosonographic guidance. A single coil was placed in 4, two coils in each of 7 patients, 4 coils in one and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 7 patients. Five patients had repeat endocoiling one month later. One of the patients re-bled during follow-up of 59 to 400 days. One patient died two months after the procedure due to spontaneous bacterial peritonitis. We report the successful use of Endocoiling with/without cyanoacrylate injection for the obliteration of gastric varices in post-cyanoacrylate gastric variceal re-bleed.
Endosonogram showing A. Blood flow in varices before endocoiling and B. absence of blood flow after endocoiling
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Su1987 Pilot Study of a New Platform for Testing EUS-FNA Needles Shyam Varadarajulu*1, Shantel Hebert-Magee1, Martha B. Pitman2, William R. Brugge3 1 Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; 2 Pathology, Massachusetts General Hospital, Boston, MA; 3Medicine, Massachusetts General Hospital, Boston, MA Background: Currently there are no reliable models for objectively testing the tissue acquisition performance of FNA needles in real disease states. Aim: To test the utility of a tumor model for evaluating technical performance of FNA needles. Methods: The HPAF-II (ATCCÒ CRL1997Ô) is a cell line developed from ascites of a human pancreatic cancer subject. 5 million cells are suspended in 0.3ml basal media and injected subcutaneously to male rats (Rattus Norvegius), 15 weeks old, weighing 250300gm and T cell deficient. At 21-28 days, the rats developed subcutaneous tumors measuring 2cm in size. Two types of FNA needles (Needle A, ProCore 22G; Needle B, Expect 22G) were used to sample the tumors using the fanning (multiple different trajectories through the tumor) technique (Needles A and B tested) and one-stroke (single trajectory through the tumor; only Needle A tested) technique. Only a single sample was procured per needle and suction was not used. The specimens were processed as a cell block and the cumulative fragment size was measured using metamorph microscopy automation and image analysis. Results: 78 FNA passes were performed using both type needles in 12 anesthetized rats. 52 of 78 (66%) passes yielded tissue that was adequate (size >12500mm2) for evaluation: fanning technique 27 (Needle A 16, Needle B 11) passes; one-stroke technique 25 (Needle A) passes. The cumulative fragment size with the fanning technique was significantly larger for Needle B (696334.6 mm2 vs. 295399.5 mm2; pZ 0.04). The cumulative fragment size with Needle A for one stroke technique was 122275.8 mm2. Limitations: The FNA passes revealed only malignant necrosis unsuitable for examination in 33% suggesting that additional studies are required to determine the optimal time for tissue acquisition during tumorigenesis. Also, only a single pass was performed with each needle. Finally, the tumor model was specific for adenocarcinoma; models for GIST cell lines and other tumors are under development. Conclusions: This preliminary but promising data suggests that the rat pancreatic cancer model may serve as an objective platform for evaluating EUS-guided tissue procurement. In the future, the model may be used to determine if FNB devices under development truly yield histological core tissue or only cytological aspirates.
Su1988 EUS-Guided Gastro-Jejunal Anastomosis Performed as a Simplified, Two-Step, Single Balloon Procedure Using a Hot Lumen-Apposing Expandable Metal Stent - A Porcine Survival Study Adrian Saftoiu*1,2, Bogdan S. Ungureanu1, Valeriu Surlin3, Stefan Patrascu3, Daniela E. Burtea1, Carmen D. Nicolau4, Florin Turcu5, Catalin Copaescu5, Peter Vilmann2 1 Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Romania; 2Endoscopy Department, Copenhagen University Hospital Herlev, Copenhagen, Denmark; 3Department of Surgery, University of Medicine and Pharmacy Craiova, Craiova, Romania; 4Center for Integrative Medicine “Lotus Life” Gastroenterology Private Hospital, Targu Mures, Romania; 5Ponderas Private Hospital, Bucharest, Romania Background: Surgical Gastro-Jejunal Anastomosis (GJA) is at present mainly performed in patients with gastric outlet obstruction. Endoscopic ultrasound (EUS) is currently under evaluation as a potential option for performing a minimal invasive Gastric Bypass through a pure endoscopic GJA approach. Objective: To assess the feasibility of a simplified two-step procedure of EUS-guided GJA in a survival pig model. Materials and Methods: Four consecutive pigs with a weight of 30 to 35 kilograms were subjected to either EUS-guided GJA or sham endoscopy procedures. All procedures were performed according to the national and international guidelines for animal use in research. GJA was performed in two simple endoscopic steps. The first step consisted of placement of an enteric balloon (SMART NaviAidTM ABC, Tel-Aviv, Israel) at 40-50 cm away from the pylorus, through a conventional colonoscope. The balloon was filled with saline solution and maintained in the desired position. The colonoscope was withdrawn, and a linear echoendoscope was advanced into the stomach. The second step consisted of EUS-imaging of the saline-filled enteric balloon and placement of a 15 mm diameter fully covered lumen apposing expandable metal stent (Boston Scientific, Marlborough, MA, USA). The balloon was easily identified and punctured directly through the gastric and jejunal walls under direct EUS-guidance with the hot Axios stent. The lumen-apposing stent was subsequently deployed and expanded bridging the gastric and jejunal lumen, thus creating the GJA. Food resumption began 24 hours after the procedure and was carried out for 3 weeks with specific doses for each pig, until necropsy was performed. Results: GJA was successful with a mean time for stent placement of 36.6 minutes with a range of 29-51 minutes. No change in pig behavior was observed after food resumption. Necropsy was performed and complete adhesions between the stomach and the jejunum wall were seen in all cases. The stent distance placement from the duodenum was confirmed after necropsy with an average of 45.5 cm from the pylorus. Significant body weight gain was not noticed at the end of the experiment. Conclusion: A simplified two-step, single balloon procedure was designed for EUS-guided GJA using a lumen-apposing expandable metal stent. The method was easy to perform and was easily applied in a porcine model as a short time procedure. Further experiments should be conducted to establish the safety and reproducibility before human use.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB417
Su1986 EUS Guided Coiling in Post Cyanoacrylate Gastric Variceal Rebleed Roy J. Mukkada*, Philip Augustine, Abraham Koshy, Antony Chettupuzha, Rajesh Antony, Mathews Chooracken, Jose F. Vadukkoot Gastroenterology, Lakeshore Hospital, Kochi, Kerala, India N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25-50%. Endocoiling is an emerging treatment modality for bleeding gastric varices. We performed endocoiling of varices in 14 patients who re-bled after cyanoacrylate injection. Endocoiling was done under endosonographic guidance. A single coil was placed in 4, two coils in each of 7 patients, 4 coils in one and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 7 patients. Five patients had repeat endocoiling one month later. One of the patients re-bled during follow-up of 59 to 400 days. One patient died two months after the procedure due to spontaneous bacterial peritonitis. We report the successful use of Endocoiling with/without cyanoacrylate injection for the obliteration of gastric varices in post-cyanoacrylate gastric variceal re-bleed.
Endosonogram showing A. Blood flow in varices before endocoiling and B. absence of blood flow after endocoiling
www.giejournal.org
Su1987 Pilot Study of a New Platform for Testing EUS-FNA Needles Shyam Varadarajulu*1, Shantel Hebert-Magee1, Martha B. Pitman2, William R. Brugge3 1 Center for Interventional Endoscopy, Florida Hospital, Orlando, FL; 2 Pathology, Massachusetts General Hospital, Boston, MA; 3Medicine, Massachusetts General Hospital, Boston, MA Background: Currently there are no reliable models for objectively testing the tissue acquisition performance of FNA needles in real disease states. Aim: To test the utility of a tumor model for evaluating technical performance of FNA needles. Methods: The HPAF-II (ATCCÒ CRL1997Ô) is a cell line developed from ascites of a human pancreatic cancer subject. 5 million cells are suspended in 0.3ml basal media and injected subcutaneously to male rats (Rattus Norvegius), 15 weeks old, weighing 250300gm and T cell deficient. At 21-28 days, the rats developed subcutaneous tumors measuring 2cm in size. Two types of FNA needles (Needle A, ProCore 22G; Needle B, Expect 22G) were used to sample the tumors using the fanning (multiple different trajectories through the tumor) technique (Needles A and B tested) and one-stroke (single trajectory through the tumor; only Needle A tested) technique. Only a single sample was procured per needle and suction was not used. The specimens were processed as a cell block and the cumulative fragment size was measured using metamorph microscopy automation and image analysis. Results: 78 FNA passes were performed using both type needles in 12 anesthetized rats. 52 of 78 (66%) passes yielded tissue that was adequate (size >12500mm2) for evaluation: fanning technique 27 (Needle A 16, Needle B 11) passes; one-stroke technique 25 (Needle A) passes. The cumulative fragment size with the fanning technique was significantly larger for Needle B (696334.6 mm2 vs. 295399.5 mm2; pZ 0.04). The cumulative fragment size with Needle A for one stroke technique was 122275.8 mm2. Limitations: The FNA passes revealed only malignant necrosis unsuitable for examination in 33% suggesting that additional studies are required to determine the optimal time for tissue acquisition during tumorigenesis. Also, only a single pass was performed with each needle. Finally, the tumor model was specific for adenocarcinoma; models for GIST cell lines and other tumors are under development. Conclusions: This preliminary but promising data suggests that the rat pancreatic cancer model may serve as an objective platform for evaluating EUS-guided tissue procurement. In the future, the model may be used to determine if FNB devices under development truly yield histological core tissue or only cytological aspirates.
Su1988 EUS-Guided Gastro-Jejunal Anastomosis Performed as a Simplified, Two-Step, Single Balloon Procedure Using a Hot Lumen-Apposing Expandable Metal Stent - A Porcine Survival Study Adrian Saftoiu*1,2, Bogdan S. Ungureanu1, Valeriu Surlin3, Stefan Patrascu3, Daniela E. Burtea1, Carmen D. Nicolau4, Florin Turcu5, Catalin Copaescu5, Peter Vilmann2 1 Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Romania; 2Endoscopy Department, Copenhagen University Hospital Herlev, Copenhagen, Denmark; 3Department of Surgery, University of Medicine and Pharmacy Craiova, Craiova, Romania; 4Center for Integrative Medicine “Lotus Life” Gastroenterology Private Hospital, Targu Mures, Romania; 5Ponderas Private Hospital, Bucharest, Romania Background: Surgical Gastro-Jejunal Anastomosis (GJA) is at present mainly performed in patients with gastric outlet obstruction. Endoscopic ultrasound (EUS) is currently under evaluation as a potential option for performing a minimal invasive Gastric Bypass through a pure endoscopic GJA approach. Objective: To assess the feasibility of a simplified two-step procedure of EUS-guided GJA in a survival pig model. Materials and Methods: Four consecutive pigs with a weight of 30 to 35 kilograms were subjected to either EUS-guided GJA or sham endoscopy procedures. All procedures were performed according to the national and international guidelines for animal use in research. GJA was performed in two simple endoscopic steps. The first step consisted of placement of an enteric balloon (SMART NaviAidTM ABC, Tel-Aviv, Israel) at 40-50 cm away from the pylorus, through a conventional colonoscope. The balloon was filled with saline solution and maintained in the desired position. The colonoscope was withdrawn, and a linear echoendoscope was advanced into the stomach. The second step consisted of EUS-imaging of the saline-filled enteric balloon and placement of a 15 mm diameter fully covered lumen apposing expandable metal stent (Boston Scientific, Marlborough, MA, USA). The balloon was easily identified and punctured directly through the gastric and jejunal walls under direct EUS-guidance with the hot Axios stent. The lumen-apposing stent was subsequently deployed and expanded bridging the gastric and jejunal lumen, thus creating the GJA. Food resumption began 24 hours after the procedure and was carried out for 3 weeks with specific doses for each pig, until necropsy was performed. Results: GJA was successful with a mean time for stent placement of 36.6 minutes with a range of 29-51 minutes. No change in pig behavior was observed after food resumption. Necropsy was performed and complete adhesions between the stomach and the jejunum wall were seen in all cases. The stent distance placement from the duodenum was confirmed after necropsy with an average of 45.5 cm from the pylorus. Significant body weight gain was not noticed at the end of the experiment. Conclusion: A simplified two-step, single balloon procedure was designed for EUS-guided GJA using a lumen-apposing expandable metal stent. The method was easy to perform and was easily applied in a porcine model as a short time procedure. Further experiments should be conducted to establish the safety and reproducibility before human use.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB417