1 Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in west Japan.

Yamao K et al. Gastrointest Endosc 2018 Feb 4.

 

Key points:

  • EUS-guided biliary drainage (EUS-BD) is becoming an alternative to percutaneous drainage (PTC) after failed or impossible ERCP;
  • Japanese researchers retrospectively evaluated EUS-BD in 39 pancreatic cancer patients with duodenal stents;
  • In 23 patients (59%) the stent overlaid major papilla;
  • Compared to ERCP through the stent, overall technical success of biliary drainage was higher for EUS-BD (95% vs 56%), especially in patients in whom the duodenal stent overlaid the papilla (93% vs 22%); Adverse event rate was similar in the groups;
  • The data from this retrospective cohort study validates the use of EUS-guided biliary drainage in patients who cannot undergo ERCP or with failed ERCP as an alternative to PTC;

 

Abstract

 

BACKGROUND AND AIMS:

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) is often performed after unsuccessful endoscopic transpapillary stent placement (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS and EUS-BD in patients with an indwelling gastroduodenal stent (GDS).

 

METHODS:

We recorded the clinical outcomes of patients at 5 tertiary medical centers who required biliary drainage after GDS placement between March 2009 and March 2014.

 

RESULTS:

Thirty-nine patients were included in this study. Patients’ mean age was 68.5 years; 23 (59.0%) were men. The GDS overlaid the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than ETS (56.0%, P <0.01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than ETS (22.2%, P <0.01) when the GDS overlaid the papilla. The overall clinical success rate of EUS-BD was also significantly higher than for ETS (90.5% versus 52.0%, respectively; P = 0.01) and there was no significant difference in the incidence of adverse events (ETS, 32.0% versus EUS-BD, 42.9%; P = 0.65).

 

CONCLUSION:

Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option in patients with an indwelling GDS that overlies the papilla. ETS remains a reasonable alternative when the papilla is not covered by the GDS.

 

2. Randomized trial comparing the Franseen and Fork-tip needles for EUS-guided fine-needle biopsy sampling of solid pancreatic mass lesions.

Bang JY et al. Gastrointest Endosc 2018 Jan 3.

 

Key points:

  • Recently EUS-fine-needle biopsy (EUS-FNB) devices have been developed; Three EUS-FNB needles are currently available on the market but few data is available concerning their performance;
  • In a RCT American researchers compared two different 22G FNB needles – a franseen (Acquire, Boston Scientific) and a fork-tip (SharkCore, Medtronic) needle;
  • Fifty patients with solid pancreatic masses were randomized to first undergo EUS with one of the two needles, followed by EUS-FNB with the alternate needle – 2 passes with each needle and additional passes with on site cytology (ROSE).
  • The authors found no difference between the amount of collected tissue, the ability to obtain a diagnostic cell block and the overall accuracy (94% – Franseen and 98% – Fork-tip).
  • The authors conclude that Franseen and Fork-tip needles performed equally well in this prospective analysis;
  • This suggests that EUS-FNB needle selection can be based on physicial preference and price. Also this new needles may obviate the need of ROSE because their diagnostic yield is greater than 90%.

 

Abstract

 

BACKGROUND AND AIMS:

Recently, a 3-plane symmetric needle with Franseen geometry and a Fork-tip biopsy needle have been developed for histologic tissue procurement. We compared 22-gauge Franseen and 22-gauge Fork-tip needles in patients undergoing EUS-guided sampling of pancreatic masses.

 

METHODS:

Fifty patients underwent sampling using both 22-gauge Franseen and 22-gauge Fork-tip needles, with randomization of needle order. Two dedicated passes were performed using both needles for cell block. Subsequent passes were performed for rapid onsite evaluation (ROSE) using both needles alternately until diagnosis was established. The main outcome was to evaluate for histologic core tissue by comparing area of total tissue, tumor, desmoplastic fibrosis, and rate of retained tissue architecture between cohorts. Other outcomes were rates of diagnostic cell block and diagnostic adequacy at ROSE.

 

RESULTS:

Final diagnosis was pancreatic cancer in 44 patients, neuroendocrine tumor in 2, lymphoma in 1, and chronic pancreatitis in 3. There was no significant difference in area of total tissue (median 6.1 [interquartie range {IQR}, 3.5-10.5] vs 8.2 mm2 [IQR, 4.0-13.0], P = .50), tumor (median .9 [IQR .3-2.8] vs 1.0 mm2 [IQR .4-2.7], P = .33), desmoplastic fibrosis (median 4.3 [IQR, 2.0-6.7] vs 5.2 mm2 [IQR, 1.7-6.1], P = .71), retained architecture (100% vs 83%, P = .25), diagnostic cell block (96.0% vs 92.0%, P = .32), and diagnostic adequacy at ROSE (94.0% vs 98.0%, P = .32) between Franseen and Fork-tip needles, respectively.

 

CONCLUSIONS:

There was no significant difference between Franseen and Fork-tip needles in yielding histologic tissue. Given their ability to yield diagnostic cell block in greater than 90% of patients, the new-generation fine-needle biopsy needles may obviate the need for ROSE.

 

 

3. Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocysts.

Aburajab M et al. Gastrointest Endosc 2017 Dec 9.

 

Key points:

  • Clogging of lumen-apposing metal stents (LAMS) can result in infection;
  • In this single-center retrospective study, the authors evaluated the effect of double-pigtail stents (DPSs) through LAMS in reducing the risk of infection of the pancreatic pseudocysts (PP);
  • Forty-seven patients had their pancreatic pseudocyst (PP) endoscopically drained: half with only LAMs and the other half with LAMs plus plastic stents;
  • PP resolution was observed in 96% of the cases. There was one perforation during LAMs placement.
  • The rate of infection was 17% (n=4) in the LAMs group versus 0% in the LAMs+plastic stent group (relative risk 0.8, p=0.054).
  • This retrospective study suggests the possibility that plastic pigtail stents through LAMS might reduce the risk of infection in PP.

 

Abstract

 

BACKGROUND AND AIMS:

Lumen-apposing metal stents (LAMSs) are used to perform necrosectomy in walled-off necrosis (WON). Although necrosectomy is not required for pancreatic pseudocyst (PP), an increasing number of PPs are also being drained with LAMSs in view of their ease of deployment. The aim of the present study was to evaluate the safety and efficacy of using LAMSs to drain PPs.

METHODS:

At one tertiary center, from January 2014 to May 2016, all consecutive patients with PPs were drained by LAMSs, and the data were retrospectively reviewed. After observing cyst-cavity infection in patients enrolled initially (Group I), a 10F double-pigtail stents (DPSs) were placed across LAMSs in the subsequent patients (Group II). Data on technical success, PP resolution, adverse events (AEs), and reintervention rates were collected.

RESULTS:

Forty-seven patients with PPs (mean size 9.5 ± 4.0 cm) were enrolled (Group I: 24, Group II: 23). There was one perforation at deployment (technical success 98%). In the remaining 46 patients, resolution of the PP was observed in 44 patients (96%). Four patients (17%) in Group I presented with PP infection requiring reinterventions. Food material was observed in the cyst cavity. None of the patients in Group II had PP infection (RR, 0.84; 95% CI, 0.71 – 1.0; p = 0.054).

CONCLUSION:

Similar to WON, LAMSs are also effective in endoscopic drainage of PPs. However, there was a trend toward higher PP infection with LAMSs, and placing a double-pigtail stent across the LAMS minimized this risk.