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T1464: 25G or 22G Needle, Which Is Better for EUS-FNA for Pancreatic Tumor? Prospective Randomized Controlled Trial
Abstracts consequence of scheduling an individual for an unwarranted resection. These observations should be taken into considerations when surveilling individuals at high risk of PC and management should be adapted accordingly.
T1464 25G or 22G Needle, Which Is Better for EUS-FNA for Pancreatic Tumor? Prospective Randomized Controlled Trial E Ryoung Choi, Tae Hoon Jang, Kee Taek Jang, Jong Kyun Lee, Kyu Taek Lee, Kwang Hyuck Lee Background and study aims: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is widely performed to diagnose pancreatic tumors. Recently 25-gauge (25G) needle is available, which is thinner and more flexible than 22-gauge (22G) for EUS-FNA. However, few studies comparing these needles were published, especially in the aspect of the internal characteristics of tumor or manipulation of endoscope. The aim of this study was to compare efficacy and limitation of 25G with 22G needles in EUS-FNA for pancreatic tumor. Patients and methods: From April 2009 to September 2009, at Samsung Medical Center (Seoul, South Korea), we randomized the patients who needed EUS-FNA for pancreatic tumor into 25G or 22G group and performed the procedure using each needle. Diagnostic accuracy and complication were analyzed prospectively in the aspect of the range of endoscopic manipulation, location and internal characteristics of pancreatic tumors. Results: Forty eight patients were assigned into 25G group, and forty five patients into 22G group. Overall accuracy for 25G and 22G needle was 89.6% (43/48) and 84.4% (38/45), respectively (p⫽0.460). The feasibility of 25G and 22G needle to evaluate histological examination was 33.3% (16/48) and 53.3% (24/45) (p⫽0.052). According to the location of pancreatic tumors, there was no difference between 25G and 22G groups; For head or uncinate process lesion, the accuracy was 86.7% and 81.8% (p⫽0.708). For body or tail lesions, the accuracy was 94.4% and 87.0% (p⫽0.618). In the view of internal characteristics of tumors, also there was no difference between 25G and 22G groups; In solid tumors, the accuracy was 85.7% and 84.4% (p⫽0.878). In cystic tumors, diagnostic yield by cytological or cystic fluid analysis was 100% and 84.6% (p⫽0.480). For head or uncinate process lesions, there was no significant difference in pathway visualization and resistance during puncture according to angulations of endoscope. For body or tail lesions, only the resistance was lower in the 25G group (p⫽0.019). Post-FNA pancreatitis occurred in one case in the 25G group. Conclusion: A 25 gauge needle can be used as efficiently as a 22 gauge needle in EUS-FNA for patients with a pancreatic tumor. Keywords: pancreatic tumor, EUS-FNA, 22 gauge, 25 gauge
T1465 EUS-Guided Cholangiography When Endoscopic Retrograde Cholangiography Failed: 6-Year Single Center Experience Monder Abusuboh Abadia, Joan Dot-Bach, Miquel Masachs Peracaula, Jordi Armengol Bertroli, Anna Benages Curell, Jose C. Salord, Sergey V. Kantsevoy, Jose Ramon Armengol-Miro BACKGROUND: Endoscopic Retrograde Cholangiography (ERC) is still the procedure of choice for biliary decompression in patients with obstructive jaundice. However, endoscopic cannulation of the major duodenal papilla could be very difficult and often impossible in patients with periampulary diverticuli, impacted stones, tumor infiltration, etc. When the ERC fails, percutaneous transhepatic drainage and surgical intervention are recommended, however, both techniques are associated with significant morbidity. Interventional Endoscopic Ultrasound guided cholangiography (IEUC) has been recently reported. OBJECTIVE: To report our 6-year experience with IEUC for biliary decompression in patients with obstructive jaundice.METHODS: For IEUC a linear array echoendoscope (Olympus, UCT, 140) was advanced into duodenum. Retroduodenal common bile duct was visualized and punctured with 19 gauge fine needle aspiration (FNA) needle. After aspiration of the bile (to document the proper position of the needle), the contrast was injected to delineate the biliary anatomy. Then the guide-wire was advanced through the needle and directed back to the duodenum for subsequent placement of the biliary duct via major papilla (rendezvous technique). If the guide-wire could not pass through the major papilla, it was directed into the proximal biliary tree and a biliary stent was placed over the wire completing creation of the supra-papillary biliaryduodenal fistula. RESULTS: For the last 6 years (2004-2009) a total of 3245 patients with obstructive jaundice were referred to our endoscopy unit for ERC. Twenty of them underwent IEUC after ERC failure. The indications for ERC were pancreatic neoplasm (n⫽18) and impacted common bile duct stones (n⫽2). The causes for ERC failure were: inability to identify the papillary orifice (n⫽1), duodenal infiltration not allowing access to the major papilla (n⫽2), periampulary diverticula (n⫽6), papillary and distal common bile duct infiltration (n⫽9). In 18 of the 20 cases (90%) biliary decompression was achieved utilizing rendezvous technique (n⫽15) or creation of a biliary-duodenal fistula (n⫽3). In 2 cases (10%) billiary decompression was not possible due to extensive infiltration of distal common bile duct and duodenum. One patient developed
AB284 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
minor bleeding during IEUC controlled with endoscopic hemostasis, and 2 patients had mild pancreatitis treated conservatively. CONCLUSION: IEUC is a safe and effective technique, which could become a valuable alternative to surgery or percutaneus transhepatic drainage when ERC is not possible.
T1466 EUS-Guided Band Ligation for Auto-Amputation of Superficial Upper Gastrointestinal Tract Lesions Julie Holinga, Michael K. Sanders, Kenneth E. Fasanella, Asif Khalid, Kevin Mcgrath Background: In addition to hemostasis, endoscopic band ligation (EBL) is used for the creation of pseudo-polyps to facilitate endoscopic resection with electrocautery. EBL without resection can be used to remove small lesions, which slough due to vascular constriction. This method of resection may confer a lower risk of bleeding and perforation. We report our experience with EUSguided EBL for auto-amputation of superficial gastrointestinal lesions of the esophagus, stomach and duodenum.Methods: A retrospective review was performed to identify patients who underwent EUS-guided EBL of superficial gastrointestinal lesions over a five year period. Patient characteristics, clinical history, endoscopic and EUS findings, pathology results (when available), complications, and findings on repeat surveillance endoscopy were reviewed. Results: Forty patients were identified: 14 males, 26 females, mean age 55.7 ⫾ 15 years [SD]. There were 13 esophageal lesions (7 stromal tumors, 6 granular cell tumors), 16 gastric lesions (15 stromal tumors, 1 carcinoid tumor) and 11 duodenal bulb lesions (all carcinoids). All lesions were incidental endoscopic findings. Pre-EUS diagnostic histology was present in 18 cases (all carcinoid and granular cell tumors). The diagnosis of stromal tumor was made by EUS appearance in the setting of previous non-diagnostic biopsies. The mean size of all lesions was 6.5 ⫾ 1.8 mm [SD](range 4 - 11 mm). 25 lesions were deep mucosal-based, 13 were submucosal, and 2 arose from the inner circular layer of the muscularis propria. One patient had 2 diminutive esophageal granular cell tumors. The patient with a gastric carcinoid carried a diagnosis of pernicious anemia. All lesions were successfully ligated with one band. To date, 25 patients have undergone follow up EGD at our institution, without evidence of a persistent lesion. Seven patients have follow up EGD still pending, 7 patients underwent follow up EGD locally, and 1 patient had no follow up (underwent RYGB). Mean time from banding to endoscopic follow up was 6.7 ⫾ 3.5 months [SD]. Two patients had post-procedure self-limited chest pain and abdominal pain, respectively. Conclusion: EUS-guided EBL is a safe, effective method for removal of small superficial gastrointestinal lesions, and may be a lower risk alternative to conventional resection with cautery. This may be an ideal modality for higher risk patients and for lesions in difficult locations. For lesions such as stromal tumors, EBL eliminates the need for surveillance EUS.
T1467 Metastatic Risk of Diminutive Rectal Carcinoid Tumors: A Need for Surveillance Rectal Ultrasound Julie Holinga, Asif Khalid, Kenneth E. Fasanella, Michael K. Sanders, Kevin Mcgrath Background: Endoscopic resection or local excision is reported to be curative for rectal carcinoid tumors ⱕ 10 mm in size. We report our experience with endoscopic rectal ultrasound (RUS) for assessment and surveillance of diminutive rectal carcinoid tumors. Methods: A retrospective review was performed to identify patients who underwent endoscopic rectal ultrasound to evaluate rectal carcinoid tumors over an 8 year period. Only rectal carcinoid tumors ⱕ 10 mm in size were included. Patient characteristics, clinical history, endoscopic and EUS findings, operative reports and pathology results were reviewed. Results: Twenty four patients were identified: 13 males, 11 females, mean age 56 ⫾ 11 years. All lesions were incidental endoscopic findings. Carcinoid tumor mean size was 5.8 ⫾ 3 mm. 14 lesions were removed by polypectomy, 7 lesions were removed by band-assisted EMR, and 3 lesions were removed by transanal resection. 17 of 24 patients have undergone RUS surveillance; mean follow up was 15.6 months. Two patients (8.3%) had a metastatic perirectal lymph node identified by surveillance RUS 17 and 26 months after initial tumor resection, respectively; each underwent EUS-FNA for cytologic confirmation. The former patient initially underwent transanal resection to remove a 5 mm carcinoid tumor with clear margins. A laparoscopic partial protectomy was ultimately performed after the metastasis (5 mm LN) was diagnosed by EUS-FNA, revealing 1/28 positive LNs. There was no pathologic evidence of residual neoplasm in the rectal wall. The latter patient underwent initial snare polypectomy of a 10 mm rectal polyp. Pathology revealed carcinoid tumor with a positive deep margin. After initial RUS was performed to exclude LNs, a transanal resection of the polypectomy site was performed; there was no pathologic evidence of residual tumor. This patient underwent eventual laparoscopic resection of the metastatic LN (5mm) with intraoperative EUS localization.Conclusions: Diminutive rectal carcinoid tumors have metastatic risk. In our series, 8.3% of patients developed metastatic perirectal lymph nodes detected by surveillance RUS. Based on our
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T1464 25G or 22G Needle, Which Is Better for EUS-FNA for Pancreatic Tumor? Prospective Randomized Controlled Trial E Ryoung Choi, Tae Hoon Jang, Kee Taek Jang, Jong Kyun Lee, Kyu Taek Lee, Kwang Hyuck Lee Background and study aims: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is widely performed to diagnose pancreatic tumors. Recently 25-gauge (25G) needle is available, which is thinner and more flexible than 22-gauge (22G) for EUS-FNA. However, few studies comparing these needles were published, especially in the aspect of the internal characteristics of tumor or manipulation of endoscope. The aim of this study was to compare efficacy and limitation of 25G with 22G needles in EUS-FNA for pancreatic tumor. Patients and methods: From April 2009 to September 2009, at Samsung Medical Center (Seoul, South Korea), we randomized the patients who needed EUS-FNA for pancreatic tumor into 25G or 22G group and performed the procedure using each needle. Diagnostic accuracy and complication were analyzed prospectively in the aspect of the range of endoscopic manipulation, location and internal characteristics of pancreatic tumors. Results: Forty eight patients were assigned into 25G group, and forty five patients into 22G group. Overall accuracy for 25G and 22G needle was 89.6% (43/48) and 84.4% (38/45), respectively (p⫽0.460). The feasibility of 25G and 22G needle to evaluate histological examination was 33.3% (16/48) and 53.3% (24/45) (p⫽0.052). According to the location of pancreatic tumors, there was no difference between 25G and 22G groups; For head or uncinate process lesion, the accuracy was 86.7% and 81.8% (p⫽0.708). For body or tail lesions, the accuracy was 94.4% and 87.0% (p⫽0.618). In the view of internal characteristics of tumors, also there was no difference between 25G and 22G groups; In solid tumors, the accuracy was 85.7% and 84.4% (p⫽0.878). In cystic tumors, diagnostic yield by cytological or cystic fluid analysis was 100% and 84.6% (p⫽0.480). For head or uncinate process lesions, there was no significant difference in pathway visualization and resistance during puncture according to angulations of endoscope. For body or tail lesions, only the resistance was lower in the 25G group (p⫽0.019). Post-FNA pancreatitis occurred in one case in the 25G group. Conclusion: A 25 gauge needle can be used as efficiently as a 22 gauge needle in EUS-FNA for patients with a pancreatic tumor. Keywords: pancreatic tumor, EUS-FNA, 22 gauge, 25 gauge
T1465 EUS-Guided Cholangiography When Endoscopic Retrograde Cholangiography Failed: 6-Year Single Center Experience Monder Abusuboh Abadia, Joan Dot-Bach, Miquel Masachs Peracaula, Jordi Armengol Bertroli, Anna Benages Curell, Jose C. Salord, Sergey V. Kantsevoy, Jose Ramon Armengol-Miro BACKGROUND: Endoscopic Retrograde Cholangiography (ERC) is still the procedure of choice for biliary decompression in patients with obstructive jaundice. However, endoscopic cannulation of the major duodenal papilla could be very difficult and often impossible in patients with periampulary diverticuli, impacted stones, tumor infiltration, etc. When the ERC fails, percutaneous transhepatic drainage and surgical intervention are recommended, however, both techniques are associated with significant morbidity. Interventional Endoscopic Ultrasound guided cholangiography (IEUC) has been recently reported. OBJECTIVE: To report our 6-year experience with IEUC for biliary decompression in patients with obstructive jaundice.METHODS: For IEUC a linear array echoendoscope (Olympus, UCT, 140) was advanced into duodenum. Retroduodenal common bile duct was visualized and punctured with 19 gauge fine needle aspiration (FNA) needle. After aspiration of the bile (to document the proper position of the needle), the contrast was injected to delineate the biliary anatomy. Then the guide-wire was advanced through the needle and directed back to the duodenum for subsequent placement of the biliary duct via major papilla (rendezvous technique). If the guide-wire could not pass through the major papilla, it was directed into the proximal biliary tree and a biliary stent was placed over the wire completing creation of the supra-papillary biliaryduodenal fistula. RESULTS: For the last 6 years (2004-2009) a total of 3245 patients with obstructive jaundice were referred to our endoscopy unit for ERC. Twenty of them underwent IEUC after ERC failure. The indications for ERC were pancreatic neoplasm (n⫽18) and impacted common bile duct stones (n⫽2). The causes for ERC failure were: inability to identify the papillary orifice (n⫽1), duodenal infiltration not allowing access to the major papilla (n⫽2), periampulary diverticula (n⫽6), papillary and distal common bile duct infiltration (n⫽9). In 18 of the 20 cases (90%) biliary decompression was achieved utilizing rendezvous technique (n⫽15) or creation of a biliary-duodenal fistula (n⫽3). In 2 cases (10%) billiary decompression was not possible due to extensive infiltration of distal common bile duct and duodenum. One patient developed
AB284 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
minor bleeding during IEUC controlled with endoscopic hemostasis, and 2 patients had mild pancreatitis treated conservatively. CONCLUSION: IEUC is a safe and effective technique, which could become a valuable alternative to surgery or percutaneus transhepatic drainage when ERC is not possible.
T1466 EUS-Guided Band Ligation for Auto-Amputation of Superficial Upper Gastrointestinal Tract Lesions Julie Holinga, Michael K. Sanders, Kenneth E. Fasanella, Asif Khalid, Kevin Mcgrath Background: In addition to hemostasis, endoscopic band ligation (EBL) is used for the creation of pseudo-polyps to facilitate endoscopic resection with electrocautery. EBL without resection can be used to remove small lesions, which slough due to vascular constriction. This method of resection may confer a lower risk of bleeding and perforation. We report our experience with EUSguided EBL for auto-amputation of superficial gastrointestinal lesions of the esophagus, stomach and duodenum.Methods: A retrospective review was performed to identify patients who underwent EUS-guided EBL of superficial gastrointestinal lesions over a five year period. Patient characteristics, clinical history, endoscopic and EUS findings, pathology results (when available), complications, and findings on repeat surveillance endoscopy were reviewed. Results: Forty patients were identified: 14 males, 26 females, mean age 55.7 ⫾ 15 years [SD]. There were 13 esophageal lesions (7 stromal tumors, 6 granular cell tumors), 16 gastric lesions (15 stromal tumors, 1 carcinoid tumor) and 11 duodenal bulb lesions (all carcinoids). All lesions were incidental endoscopic findings. Pre-EUS diagnostic histology was present in 18 cases (all carcinoid and granular cell tumors). The diagnosis of stromal tumor was made by EUS appearance in the setting of previous non-diagnostic biopsies. The mean size of all lesions was 6.5 ⫾ 1.8 mm [SD](range 4 - 11 mm). 25 lesions were deep mucosal-based, 13 were submucosal, and 2 arose from the inner circular layer of the muscularis propria. One patient had 2 diminutive esophageal granular cell tumors. The patient with a gastric carcinoid carried a diagnosis of pernicious anemia. All lesions were successfully ligated with one band. To date, 25 patients have undergone follow up EGD at our institution, without evidence of a persistent lesion. Seven patients have follow up EGD still pending, 7 patients underwent follow up EGD locally, and 1 patient had no follow up (underwent RYGB). Mean time from banding to endoscopic follow up was 6.7 ⫾ 3.5 months [SD]. Two patients had post-procedure self-limited chest pain and abdominal pain, respectively. Conclusion: EUS-guided EBL is a safe, effective method for removal of small superficial gastrointestinal lesions, and may be a lower risk alternative to conventional resection with cautery. This may be an ideal modality for higher risk patients and for lesions in difficult locations. For lesions such as stromal tumors, EBL eliminates the need for surveillance EUS.
T1467 Metastatic Risk of Diminutive Rectal Carcinoid Tumors: A Need for Surveillance Rectal Ultrasound Julie Holinga, Asif Khalid, Kenneth E. Fasanella, Michael K. Sanders, Kevin Mcgrath Background: Endoscopic resection or local excision is reported to be curative for rectal carcinoid tumors ⱕ 10 mm in size. We report our experience with endoscopic rectal ultrasound (RUS) for assessment and surveillance of diminutive rectal carcinoid tumors. Methods: A retrospective review was performed to identify patients who underwent endoscopic rectal ultrasound to evaluate rectal carcinoid tumors over an 8 year period. Only rectal carcinoid tumors ⱕ 10 mm in size were included. Patient characteristics, clinical history, endoscopic and EUS findings, operative reports and pathology results were reviewed. Results: Twenty four patients were identified: 13 males, 11 females, mean age 56 ⫾ 11 years. All lesions were incidental endoscopic findings. Carcinoid tumor mean size was 5.8 ⫾ 3 mm. 14 lesions were removed by polypectomy, 7 lesions were removed by band-assisted EMR, and 3 lesions were removed by transanal resection. 17 of 24 patients have undergone RUS surveillance; mean follow up was 15.6 months. Two patients (8.3%) had a metastatic perirectal lymph node identified by surveillance RUS 17 and 26 months after initial tumor resection, respectively; each underwent EUS-FNA for cytologic confirmation. The former patient initially underwent transanal resection to remove a 5 mm carcinoid tumor with clear margins. A laparoscopic partial protectomy was ultimately performed after the metastasis (5 mm LN) was diagnosed by EUS-FNA, revealing 1/28 positive LNs. There was no pathologic evidence of residual neoplasm in the rectal wall. The latter patient underwent initial snare polypectomy of a 10 mm rectal polyp. Pathology revealed carcinoid tumor with a positive deep margin. After initial RUS was performed to exclude LNs, a transanal resection of the polypectomy site was performed; there was no pathologic evidence of residual tumor. This patient underwent eventual laparoscopic resection of the metastatic LN (5mm) with intraoperative EUS localization.Conclusions: Diminutive rectal carcinoid tumors have metastatic risk. In our series, 8.3% of patients developed metastatic perirectal lymph nodes detected by surveillance RUS. Based on our
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