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Colonic stent placement in patients with large-bowel obstruction (LBO) secondary to extracolonic malignancy (ECM) has been evaluated in small series with heterogeneous results. Our aim is to better characterize the technical and clinical success of colonic stent placement and to identify factors that affect this success in ECM patients.All patients at a single high-volume center who presented for colonic stent placement for LBO because of ECM between 2001 and 2012 were retrospectively identified. The outcomes of interest were technical success, clinical success, stent occlusion rate, and overall survival.A total of 187 patients were identified. Mean age was 61.9 years (range, 23-89), and 150 (80.2%) were women. The most common malignancy type was urogynecologic (n = 104) and most common location sigmoid colon (n = 128). Overall, 142 patients (75.9%) achieved technical success and 102 patients (54.5%) clinical success. Radiographic presence of peritoneal carcinomatosis (P .001) and multifocal disease (P .001) were associated with both decreased technical and clinical success. Procedure-related adverse events were seen in 12 patients (6.4%). In patients with clinical success, the incidence of stent occlusion at 3 months was 14.7% (95% confidence interval, 7.8%-21.6%) and was higher in patients with prior radiation therapy (P = .011). The median overall survival for all patients from time of attempted stent placement was 3.3 months (95% confidence interval, 3.0-4.1).This study represents the largest retrospective series of colonic stent placement for LBO in ECM patients in the literature. Our technical success rate of 75.9%, clinical success rate of 54.5%, and 3-month stent occlusion rate of 14.7% suggest that stent placement is a viable palliative option for patients with advanced disease because of ECM. Patients with peritoneal carcinomatosis and multifocal disease have reduced technical and clinical success. However, these factors should not dissuade an attempt at stent placement, if risk-to-benefit analysis is favorable.

ERCP with self-expandable metallic stent (SEMS) placement provides reliable and durable relief of malignant biliary obstruction. Our objective was to compare efficacy and adverse outcomes between uncovered SEMSs (USEMSs) and covered SEMSs (CSEMSs).A retrospective cohort study was performed of all consecutive patients who underwent ERCP with SEMS placement for the management of a malignant bile duct stricture. Comparative analyses on clinical success, patency duration, stent dysfunction, and adverse outcomes were performed. Univariate and multivariable analyses were performed to identify factors associated with stent dysfunction.Six hundred forty-five patients underwent SEMS placement for the management of malignant bile duct stricture from 2008 to 2016. CSEMSs and USEMSs had similar rates of clinical success in relief of bile duct obstruction (93.0% vs 92.1%, respectively; P = .69) and patency duration (546.7 vs 557.9 days, P = .14). Among those with an intact gallbladder, the incidence of acute cholecystitis was higher in the CSEMS group compared with the USEMS group (7.8% vs 1.2%; P .001). In the multivariable analysis, CSEMS use was associated with increased risk of stent migration (hazard ratio, 10.7; 95% confidence interval, 4.1-27.7).CSEMSs and USEMSs have similar clinical success rates and patency durations in management of malignant bile duct stricture. CSEMSs, however, are associated with increased rates of migration and cholecystitis. Comparable efficacy and superior safety profile of USEMSs render a compelling argument for its place as the preferred choice of SEMSs in the management of malignant biliary stricture.

Background and Aims EUS-guided choledochoduodenostomy (EUS-CDS) using conventional tubular stents has been successfully performed. However, EUS-CDS carries a high risk of bile leakage with attendant adverse events. This study aimed to prospectively evaluate the long-term outcome of EUS-CDS using a dedicated lumen-apposing metal stent (LAMS). Methods Nineteen patients (mean age, 70.6 years; 12 men) with unresectable malignant diseases were treated in 5 tertiary referral centers. EUS-CDS was performed using a fully covered LAMS with a cautery-enhanced delivery system for EUS-CDS. Results All stents were successfully deployed without any adverse events. Jaundice improved in 79% of the patients within 7 days and finally in 95%. In 95% of patients the stents remained in good anastomotic position without migration or dislocation during the follow-up period (median, 184 days; range, 12-819). One patient had a fever the day after stent placement. During the follow-up period 5 patients had secondary stent obstruction because of food residue (n = 2), kinking (n = 1), suspected tumor ingrowth (n = 1), and spontaneous dislodgement (n = 1). Five patients developed obstruction in the second portion of the duodenum. The overall adverse event rate was 36.8% (7/19), mostly with mild severity. Conclusions This study revealed that the novel dedicated LAMS used has high technical and clinical success rates for EUS-CDS. The adverse events and patency rates are inferior to the historically reported data of a conventional transpapillary metal stent. Development of a more suitable dedicated LAMS is anticipated.

Background and Aims Two second-generation, flexible EUS fine-needle biopsy (FNB) needles have been marketed recently in the United States. Thus far, there have been no comparative studies of the diagnostic yield of these needles. The aim of this study was to compare the diagnostic yield achieved with FNB by using 1 needle during 1 time period and the other needle during a second time period. Methods Consecutive patients with solid lesions undergoing EUS-FNB by using 1 of two 22-gauge FNB needles (Franseen needle or fork-tip) at 2 different time intervals were included. The final diagnosis was based on positive pathology results. In cases of a negative pathology result, the final diagnosis was based on clinical and imaging follow-up. Results A total of 194 lesions (97 in each group) were sampled in 179 patients. Rapid on-site evaluation (ROSE) was used in 12% of cases. The overall diagnostic yield was lower in the Franseen needle group compared with the fork-tip needle group (61/97 [63%] vs 75/97 [77%], odds ratio (OR) 2.01, 1.07-3.8; P = .027). Similarly, subanalysis of the yield for solid pancreatic masses demonstrated a lower yield with the Franseen needle (34/53 [64%] vs 40/47 [85%], OR 3.4, 9.1-8.9; P = .017). Multivariate analysis controlling for the number of passes, site, and lesion size did not have any effect on diagnostic yield. There were no adverse events in either group. Conclusion In this first, large, single-center comparative cohort study of 2 new, second-generation EUS-FNB needles of different design, the diagnostic yield when used primarily without ROSE was high in both groups but was significantly higher when a fork-tip needle was used.

Background and Aims Self-expandable metal stents (SEMSs) are used for palliation of malignant gastric outlet obstruction (GOO). Studies comparing covered SEMSs (C-SEMSs) and uncovered SEMSs (U-SEMSs) have led to inconclusive results. We compared efficacy and safety of C-SEMSs versus U-SEMSs in patients with GOO. Methods We searched MEDLINE, EMBASE, and Cochrane Library from 2000 to 2019 to identify available studies comparing C-SEMSs versus U-SEMSs in patients with GOO. Primary outcomes were stent survival and patient survival, whereas secondary outcomes were clinical and technical success, Gastric Outlet Obstruction Score System (GOOSS) score after the procedure, overall adverse events, reintervention rate, dysfunction rate, stent occlusion, and stent migration. Results Overall, 7 randomized controlled trials and 9 observational studies were identified that included 1741 patients. C-SEMSs were associated with higher stent survival (hazard ratio, .68; 95% confidence interval [CI], .48-.96), whereas patient survival did not statistically significantly differ between C-SEMS and U-SEMS groups (hazard ratio, .96; 95% CI, .75-1.23). Clinical and technical success were not statistically different between groups (odds ratios, 1.1 [95% CI, .76-1.61] and .69 [95% CI, .21-2.3], respectively). There were no differences in terms of overall adverse events, reintervention rate, dysfunction rate, and GOOSS rate ≥2 after SEMS placement. U-SEMSs were associated with a higher rate of occlusion (odds ratio, .34; 95% CI, .21-.53) and C-SEMSs with a higher rate of migration (odds ratio, 4.28; 95% CI, 2.79-6.57). Conclusions C-SEMSs were associated with higher stent survival (time between stent deployment and stent dysfunction) compared with U-SEMSs, whereas no differences in terms of patient survival (time between stent deployment and patient's death) emerged. However, U-SEMSs were associated with higher risk of occlusion and C-SEMSs with higher risk of migration. Further studies using new C-SEMSs with an antimigration system are needed.

Contemporary EUS-guided FNA techniques involve the use of a needle, with an air column within the lumen, with or without suction. We describe a novel technique with an aim to improve the quality of the aspirate.To compare a novel "wet suction" technique (WEST) with the conventional FNA technique (CFNAT) of EUS-guided FNA using a 22-gauge FNA needle.Prospective, single-blind, and randomized trial.Two large tertiary-care hospitals.All consecutive adult patients presenting for EUS with possible FNA of solid lesions were offered the chance to participate in the study.All lesions were sampled with the same needle by using alternating techniques. Patients were randomized to the WEST versus the CFNAT for the first pass. If the first pass was made with the WEST, the second pass was made with the CFNAT, and subsequent passes were made in an alternating manner by using the same sequence. All FNAs were performed using 22-gauge needles.Specimen adequacy, cellularity, and blood contamination of EUS-guided FNA aspirates graded on a predefined scale.The WEST yielded significantly higher cellularity in a cell block compared with the CFNAT, with a mean cellularity score of 1.82±0.76 versus 1.45±0.768 (P.0003). The WEST cell block resulted in a significantly better specimen adequacy of 85.5% versus 75.2% (P.035). There was no difference in the amount of blood contamination between the 2 techniques.Lack of cross check and grading by a second cytopathologist.The novel WEST resulted in significantly better cellularity and specimen adequacy in cell blocks of EUS-guided FNA aspirate of solid lesions than the CFNAT.

Background Malignant gastric outlet obstruction is often treated by stent placement. Objective To investigate the outcomes of stent placement in the palliative treatment of malignant neoplasms. Design Prospective, observational, multicenter registry. Setting Six tertiary care centers in 5 countries. Patients A total of 108 adult patients with malignant gastric outlet obstruction. Interventions Placement of an uncovered, self-expandable, metal duodenal stent. Main Outcome Measurements The primary endpoint was stent patency at 14 days after stent implantation. Secondary endpoints included stent patency at 1, 2, 3, and 6 months, gastric outlet obstruction scoring system (GOOSS) scores at 14 days and 1, 2, 3, and 6 months after stent deployment, technical success, adverse events, and patient survival (ie, confirmed duration of the implant). Results Technical success was achieved in 99.1% of stent placements. Stent patency at 14 days was 94.6%. Kaplan-Meier estimates of stent patency were 92.9% at 1 month, 86.2% at 2 months, 81.9% at 3 months, and 63.4% at 6 months. At 14 days, GOOSS scores increased by a median of 1 point. The overall GI adverse event rate was 32.4%; however, the stent-related adverse event rate was 19.4%. The median implant duration was 47 days (range 0-195 days). Limitations Observational study, no control group. Conclusions Duodenal stent placement resulted in prompt relief of malignant gastric outlet obstruction and improved GOOSS scores. (Clinical trial registration number: NCT00991614.)

Background and Aims Cancer patients are prone to thrombocytopenia and neutropenia, which increase the risk of bleeding and infection. We assessed the safety of endoscopic procedures in cancer patients with thrombocytopenia and/or neutropenia. Methods We studied consecutive cancer patients with thrombocytopenia and/or neutropenia who underwent endoscopic procedures from 2010 through 2015. Neutropenia was defined as an absolute neutrophil count (ANC) 3 /μL. Univariate and multivariate generalized estimating equation models were used to assess factors associated with risk of adverse events (AEs) or death. Results We identified 588 patients who underwent 783 procedures; 608 procedures were performed in the setting of thrombocytopenia and 675 procedures in the setting of neutropenia. Concurrent neutropenia and thrombocytopenia were recorded in 500 endoscopies. Twenty-four patients (4.1%) experienced infectious AEs, whereas 29 (4.9%) experienced bleeding AEs within 1 week of the procedure. On multivariate analysis, platelet count ≤50 × 10 3 /μL was associated with risk of bleeding AEs. In contrast, poor performance status was associated with increased risk of infection AEs ( P P 3 /μL ( P 3 /μL after the procedure, with a baseline platelet count of ≤20 × 10 3 /μL before the procedure, was associated with significant risk of bleeding AEs compared with a platelet count >20 × 10 3 /μL after the procedure ( P 50 × 10 3 /μL after the procedure, the bleeding risk after the procedure was greatly reduced ( P Conclusions Endoscopic procedures are relatively safe in cancer patients with platelet count >50 × 10 3 /μL. Nevertheless, a platelet count of ≥20 × 10 3 /μL could be an appropriate threshold for platelet transfusion if 50 × 10 3 /μL is difficult to achieve. The functional status of the patient, in the absence of the need for urgent or necessary endoscopic interventions, should be considered when deciding whether to perform endoscopy. The risk of procedure and the ANC did not seem to affect the outcomes.

Background Most endosonographers use an EUS needle with an internal stylet during EUS-guided FNA (EUS-FNA). Reinserting the stylet into the needle after every pass is tedious and time-consuming, and there are no data to suggest that it improves the quality of the cytology specimen. Objective To compare the samples obtained by EUS-FNA with and without a stylet for (1) the degree of cellularity, adequacy, contamination, and amount of blood and (2) the diagnostic yield of malignancy. Design Prospective,single-blind, randomized, controlled trial. Setting Two tertiary care referral centers. Patients Patients referred for EUS-FNA of solid lesions. Intervention Patients underwent EUS-FNA of the solid lesions, and 2 passes each were made with a stylet and without a stylet in the needle. The order of the passes was randomized, and the cytopathologists reviewing the slides were blinded to the stylet status of passes. Main Outcome Measurements Degree of cellularity, adequacy, contamination, amount of blood, and the diagnostic yield of malignancy in the specimens. Results A total of 101 patients with 118 lesions were included in final analysis; 236 FNA passes were made, each with and without a stylet. No significant differences were seen in the cellularity ( P = .98), adequacy of the specimen ( P = .26), contamination ( P = .92), or significant amount of blood ( P = .61) between specimens obtained with and without a stylet. The diagnostic yield of malignancy was 55 of 236 specimens (23%) in the with-stylet group compared with 66 of 236 specimens (28%) in the without-stylet group ( P = .29). Limitations Endosonographers were not blinded to the stylet status of the passes. Conclusions Using a stylet during EUS-FNA does not confer any significant advantage with regard to the quality of the specimen obtained or the diagnostic yield of malignancy. (Clinical trial registration number: NCT 01213290).

Unresectable malignant biliary strictures are generally managed by palliative stent placement for drainage of biliary tree. Recently, radiofrequency ablation (RFA) has been used to improve the patency of biliary stents in these patients. Several studies have evaluated the effectiveness of biliary stent placement with RFA on stent patency and patient survival with variable results. We performed this meta-analysis to evaluate the efficacy and safety of biliary stent placement with RFA compared with stent placement alone in patients with malignant biliary strictures.We performed a comprehensive search of electronic databases for all studies comparing RFA with biliary stent placement versus stent placement only. Measured outcomes included patient survival, stent patency, and procedure-related adverse events. An inverse variance method was used to pool data on stent patency into a random-effects model. Cox-regression analysis was used to calculate hazard ratio for survival analysis. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework to interpret our findings.Nine studies (including 2 abstracts) with a total of 505 patients were included in the meta-analysis. The pooled weighted mean difference in stent patency was 50.6 days (95% confidence interval [CI], 32.83-68.48), favoring patients receiving RFA. Pooled survival analysis of the reconstructed Kaplan-Meier data showed improved survival in patients treated with RFA (hazard ratio, 1.395; 95% CI, 1.145-1.7; P .001). However, RFA was associated with a higher risk of postprocedural abdominal pain (31% vs 20%, P = .003). Our analysis did not show significant difference between the RFA and stent placement-only groups with regard to the risk of cholangitis, acute cholecystitis, pancreatitis, and hemobilia.In the light of this limited data based on observational studies, RFA was found to be safe and was associated with improved stent patency in patients with malignant biliary strictures. In addition, RFA may be associated with improved survival in these patients.

Background Placement of biliary stents is effective for palliation of unresectable hilar malignant biliary obstruction. However, when bilateral self-expandable metal stents (SEMSs) are used, placement can be technically challenging. In many studies, side-by-side placement is performed, although it is unclear whether this is the most anatomical and functional approach. Objective We sought to assess the technical feasibility and effectiveness of deploying bilateral SEMSs with a stent-within-stent approach using commercially available stents with a large cell width. Design Retrospective study. Setting Tertiary care medical center. Patients Patients with malignant biliary hilar obstruction referred for endoscopic palliation of obstructive jaundice. Main Outcome Measurements Technical success, ie, successful bilateral SEMS placement across the stricture; functional success, ie, decrease in pretreatment bilirubin level; early and late complications; and stent patency. Results Bilateral biliary drainage was attempted and successfully established in 21 patients with malignant hilar obstruction (15 men, 6 women; mean age 63.7 [standard deviation 13.9] years), resulting in clinical improvement of obstructive symptoms. Median follow-up was 6.14 months (interquartile range 3.5-9.5 months). There were 1 (5%) early and 7 (33%) late stent occlusions that required endoscopic reintervention. The 30-day mortality rate was 10% (2 deaths). Limitations Retrospective study of a series of cases treated at a tertiary care center by expert endoscopists. Conclusions This simple technique was performed by using an open-cell expandable metal stent is technically feasible and easy and allows bilateral placement of SEMSs in patients with unresectable hilar malignancy.

Background Covered self-expandable metallic stents (SEMSs) are designed to prevent tumor ingrowth and can be removed if necessary. Only limited comparative data are available on the performance of covered SEMSs after primary placement versus reintervention. Objective To assess the effectiveness and safety of covered SEMS placement either as primary treatment or reintervention in patients requiring palliation of malignant biliary obstruction. Design Retrospective clinical cohort study. Setting Tertiary referral center. Patients This study involved 104 patients with unresectable malignant biliary strictures. Intervention Covered biliary SEMS placement. Main Outcome Measurements Stent patency, technical success, and patient survival. Results Covered SEMSs were placed as primary treatment in 48 patients (46%), and reintervention was performed in 56 patients (54%). At 3, 6, and 12 months thereafter, the Kaplan-Meier estimated fractions of all patients with patent stents were 94%, 84%, and 58%, respectively. Covered SEMSs remained patent until the patient's death in 75 of 89 nonsurvivors (84%). Although patency rates 3, 6, and 12 months after primary placement (100%, 93%, and 82%, respectively) were higher than those after reintervention (90%, 78%, and 48%, respectively), the differences were not statistically significant ( P = .057). Overall, the most frequent adverse events were cholangitis (7%) and stent migration (4%). Limitations The distribution of stricture locations differed among the groups, and survival data suggested the presence of more extensive disease in the primary treatment group at baseline. Conclusion The clinical utility and safety of primary covered SEMS placement were confirmed. This study provides the most extensive evidence to date that reintervention with a covered SEMS can provide a useful palliative option.

Background Malignant biliary obstruction frequently portends a poor prognosis. Palliative treatment with stenting is often required to alleviate symptoms and potentially prevent adverse events. Objectives The aims of our study were (1) to evaluate the clinical difference between self-expandable metal stents (SEMSs) and plastic stents (PSs) in both hilar and distal malignant biliary obstruction on occlusion rate and 30-day mortality rate (primary outcomes) and stent insertion success rate, therapeutic failure, reintervention rate, and adverse events (secondary outcomes); (2) to compare unilateral stenting with bilateral stenting in hilar malignant obstruction in terms of occlusion rate and 30-day mortality rate (primary outcomes) and insertion success rate, therapeutic failure, and adverse events (secondary outcomes). Methods PubMed, Embase, and Cochrane databases were searched for studies that provided data about malignant biliary obstruction and stent therapy. We included randomized, controlled trials (RCT), prospective observational cohort, and retrospective case-control studies. The quality of each included RCT study was assessed by the Jadad scale. Mantel-Haenszel odds ratios (ORs) and mean differences were calculated by using a random-effects model. Results Nineteen studies involving 1989 patients (1045 SEMSs and 944 PSs) were included for the comparison of SEMSs and PSs. We also included 7 studies that compared unilateral with bilateral stenting involving 634 patients (346 unilateral and 268 bilateral). Our meta-analysis confirmed that SEMSs are associated with a statistically significant lower risk of occlusion compared with PSs in the short term (OR 0.27; 95% confidence interval [CI], 0.13-0.60) and long term (OR 0.38; 95% CI, 0.28-0.53). SEMSs had a lower 30-day occlusion rate than PSs in both hilar malignant obstruction (OR 0.16; 95% CI, 0.04-0.62) and distal malignant obstruction (OR 0.36; 95% CI, 0.14-0.93). SEMSs had a lower long-term occlusion rate compared with PSs in hilar malignant obstruction (OR 0.28; 95% CI, 0.19-0.39) and distal malignant obstruction (OR 0.42; 95% CI, 0.27-0.64). The 30-day mortality rate was similar with SEMSs and PSs (OR 0.74; 95% CI, 0.47-1.17). Therapeutic failure was more likely when using PSs (13%) compared with SEMSs (7%) (OR 0.43; 95% CI, 0.27-0.67). SEMSs required fewer reinterventions compared with PSs (mean difference, -0.49; 95% CI, -0.8 to -0.19). The incidence of cholangitis was statistically lower with SEMSs (8% vs 21%) (OR 0.41; 95% CI, 0.22-0.76). Bilateral stenting for hilar obstruction was not associated with a lower obstruction rate than unilateral stenting (OR 1.49; 95% CI, 0.77-2.89) or a lower 30-day mortality rate (OR 0.73; 95% CI, 0.29-1.79). There was no statistical difference in therapeutic failure (OR 1.47; 95% CI, 0.77-2.89) or cholangitis incidence (OR 0.61; 95% CI, 0.27-1.38). Conclusion SEMSs are associated with a statistically significantly lower occlusion rate, less therapeutic failure, less need for reintervention, and lower cholangitis incidence. There was no statistically significant difference in occlusion rate, therapeutic failure, and cholangitis incidence with bilateral stenting. Guideline recommendations may need to be modified to reflect clear and compelling data demonstrating the benefit of SEMSs in patients with malignant biliary obstruction. Bilateral stenting should be avoided because it has no benefit over unilateral stenting in terms of occlusion rate or therapeutic failure.

Background We report our data in 35 patients who underwent preoperative conventional and fluorescence-based staging laparoscopy. We use the data to address the questions of whether fluorescence examination increases the yield of metastatic lesions and alters treatment intervention. Methods Fluorescence laparoscopy was successfully performed in 30 patients with GI malignancies. After sensitization with 5-aminolevulinic acid, conventional white-light mode and fluorescence-light laparoscopies were sequentially performed. A suspected malignancy was biopsied. Observations In 5 patients, examinations were incomplete because of adhesions. In 9 of 10 patients, hepatic or peritoneal metastases were detected by white-light examination. In 4 of these 9, blue-light examination yielded more metastatic lesions. In one patient with no lesions by white- or blue-light examination, surgery revealed hepatic metastasis in a location not accessible to laparoscopic examination. In 18 patients, surgery confirmed the absence of metastatic lesions. Conclusions A fluorescence, blue-light examination yielded more lesions than the conventional white-light examination but did not alter treatment intervention and did not enhance yield when metastatic lesion is in an inaccessible location. Continued research should focus on whether treatment intervention will be altered by the fluorescence examination.

Background Few data are available concerning the frequency of bacteremia after diagnostic EUS or EUS-guided FNA. This study was undertaken to provide these data and to determine whether present guidelines for prophylactic administration of antibiotics to prevent endocarditis during upper endoscopy are applicable to EUS and EUS-guided FNA. Methods A total of 100 patients who were to undergo diagnostic EUS of the upper-GI tract and 50 who were to have upper-GI EUS-guided FNA were enrolled in this prospective study. Blood cultures were obtained before and within 5 minutes after the conclusion of the procedure. In case of bacterial growth, patients were observed for at least 3 days for signs of infection. Results After diagnostic EUS, significant bacteremia was found in two patients with esophageal carcinoma (2%: 95% CI[0%, 4.8%]) and after EUS-guided FNA in two patients (4%: 95% CI[0%, 9.6%]). The difference was not statistically significant. None of these patients developed clinical signs of infection. Risk factors predisposing to bacteremia could not be identified. Conclusion The frequency of bacteremia after EUS, with and without FNA, is within the range of that for diagnostic upper endoscopy. Therefore, the same recommendations for prophylactic administration of antibiotics to prevent endocarditis may be applied in patients undergoing EUS and EUS-guided FNA. The role of esophageal cancer as a predisposing factor to EUS-associated infection remains uncertain.

Background: The aims of this study were to determine the rate of false-positive diagnosis with EUS-guided fine-needle aspiration and to identify factors contributing to this type of error. Methods: The records of 577 patients undergoing EUS-guided fine-needle aspiration were reviewed and a subset of 188 patients with malignant cytology who underwent surgery was identified. Operative histopathology was compared with EUS-guided fine-needle aspiration cytopathology and false-positive cases were identified. An experienced cytopathologist, who was not involved with the original interpretation of the specimens, reviewed these cases to identify any factor(s) contributing to the errors. Results: Three cases of false-positive diagnosis were identified (1.6%; 95% CI [0.3%, 4.6%]). By aspiration site, the false-positive rates were as follows: pancreas 2/39 (5.1%), 95% CI [0.6%, 17.3%]; lymph nodes 1/136 (0.7%), 95% CI [0.02%, 4.0%]; and other sites 0/13, 95% CI [0.0%, 24.7%]. In both instances of a false-positive diagnosis for a pancreatic aspiration cytologic specimen, interpretative errors were identified. The false-positive interpretation of cytologic material aspirated from a lymph node occurred in a patient without any evidence for malignancy at surgery. In 111 patients with confirmed esophageal, gastric, or rectal malignancy undergoing EUS-guided fine-needle aspiration of nonperitumoral lymph nodes, there was no false-positive diagnosis, suggesting that specimen contamination by luminal tumor is rare. Conclusion: The overall rate of false-positive diagnosis for EUS-guided fine-needle aspiration is similar to that reported for other modalities. Most false-positive diagnoses are caused by interpretation errors. (Gastrointest Endosc 2002;56:868-72.)

Innovation everywhere for everybody - this is the way we can summarize the 2014 Digestive Disease Week, which was held in Chicago, Illinois, last May. Many sessions introduced new innovative materials and concepts. From the robot of the future to the simplest ideas, the congress was fertile and sometimes full of surprises. Abstracts representing significant progress and innovations in the field of digestive endoscopy are reviewed here.

Catheter US probes must rely on luminal water to create images because they do not incorporate a water-filled balloon such as that used with a designated echoendoscope. The purpose of this study is to determine the effectiveness and safety of a balloon sheath for the US catheter system.Catheter EUS was performed on 50 patients by using a 2.3 mm 12 MHz or 20 MHz catheter probe. Catheter EUS was used in 47 cases, and a newly developed water-filled balloon sheath was used in 41 cases. Both devices were used in 39 cases. Procedure time, depth of ultrasound penetration, and a subjective assessment of image quality and ease of use were recorded, along with TMN stage as applicable. Catheter EUS findings were confirmed with a standard radial scanning echoendoscopy (S-EUS) in 18 cases.Catheter probe EUS (C-EUS) and catheter probe plus balloon (CB-EUS) imaging was obtained of 25 esophageal, 8 gastric, 4 rectal, 1 biliary, and 1 duodenal lesion. Time required for the ultrasound portion of the examination was identical with C-EUS and CB-EUS. Depth of penetration increased with CB-EUS with both the 12 MHz and 20 MHz probes (p0.05). Subjective assessment of image clarity improved when CB-EUS was used in the esophagus. C-EUS failed to identify 2 esophageal cancers and 2 sets of paraesophageal lymph nodes, and understaged 1 esophageal cancer. The remaining 14 cancers were staged identically by both modalities. The catheter probes with and without the balloon sheath were easy to use, even in markedly narrow esophageal strictures. CB-EUS did not significantly improve resolution in the stomach or rectum. S-EUS confirmed findings of CB-EUS in all 18 cases in which both instruments were used. There were no procedure-related complications.For esophageal lesions, CB-EUS improves images compared with C-EUS, and enhances depth of penetration without prolonging or encumbering the examination. CB-EUS offers no advantage over C-EUS in organs other than the esophagus. S-EUS, when possible, remains the preferred imaging modality for esophageal cancers because of the ability to image the celiac axis and other deep structures.

Background: This study assesses the cost savings associated with using endoscopic ultrasound (EUS) before endoscopic retrograde cholangiopancreatography (ERCP) for evaluating patients with suspected obstructive jaundice. Methods: One hundred forty-seven patients with obstructive jaundice of unknown or possibly neoplastic origin had EUS as their first endoscopic procedure. With knowledge of the final diagnosis and actual management for each patient, their probable evaluation and outcomes and their additional costs were reassessed assuming that ERCP would have been performed as the first endoscopic procedure. Also calculated were the additional costs incurred if EUS were unavailable for use after ERCP and had to be replaced by computed tomography or other procedures. Results: The final diagnoses in these patients included malignancies (65%), choledocholithiasis or cholecystitis (18%), "medical jaundice" (11%), and miscellaneous benign conditions (6%). Fifty-four percent had EUS-guided fine-needle aspiration but only 53% required ERCP after EUS. An EUS-first approach saved an estimated $1007 to $1313/patient, but the cost was $2200 more if EUS was unavailable for use after ERCP. Significant savings persisted through sensitivity analysis. Conclusions: Performing EUS with EUS-guided fine-needle aspiration as the first endoscopic procedure in patients suspected to have obstructive jaundice can obviate the need for about 50% of ERCPs, helps direct subsequent therapeutic ERCP, and can substantially reduce costs in these patients. (Gastrointest Endosc 2001;53:475-84.)

Background: This study assessed agreement between provisional and endoscopic diagnoses for patients with dyspepsia undergoing initial endoscopy, and examined variation between clinicians at 2 hospitals. Methods: This was a retrospective review of 423 consecutive patients. Results: Crude percentage agreement ranged from 55% to 97%. Kappa scores revealed poor agreement: peptic ulcers (0.11: 95% CI [0.05, 0.17]); gastroesophageal reflux disease (0.29: 95% CI [0.20, 0.38]); benign esophageal stricture (0.33: 95% CI [0.08, 0.58]); and cancer (0.12: 95% CI [−0.12, 0.36]). Positive and negative predictive values for cancer and benign esophageal stricture showed that agreement for a negative diagnosis was almost perfect, whereas agreement for a positive diagnosis was low. Only 17% of patients with cancer were given an accurate provisional diagnosis. Accuracy of diagnosis did not vary substantially between hospitals. Conclusions: Crude percentage agreement is misleading. Emphasis should be placed on better prediction of cancer, benign esophageal stricture, and peptic ulcer disease. Accuracy of provisional diagnosis in everyday practice is no worse than that found in prospective studies in which clinicians knew a priori that diagnoses would be scrutinized. The difficulty of predicting diagnoses supports increased reliance on endoscopy. (Gastrointest Endosc 2001;53:283-8.)

Endoscopic gastroduodenal stenting for malignant gastric outlet obstruction recently has become more effective, but the factors that predict gastroduodenal stenting outcomes are poorly defined. This multicenter retrospective cohort study evaluated the clinical outcomes of gastroduodenal stenting in malignant gastroduodenal obstruction and identified factors predicting clinical ineffectiveness, stent dysfunction, and adverse events.All consecutive patients with malignant gastroduodenal obstruction who underwent through-the-scope gastroduodenal stenting from 2009 to 2014 at 4 tertiary-care medical centers were identified. Clinically ineffective stenting was defined as symptom recurrence and a gastric outlet obstruction scoring system (GOOSS) score 2.Of the 278 patients (mean age ± standard deviation [SD] 71.7 ± 11.4 years), 121 (43.5%) and 87 (31.3%) had pancreatic and gastric cancer, respectively. Technical success was achieved in 277 patients (99.6%). GOOSS scores rose from 0.5 ± 0.6 to 2.6 ± 0.8. Stenting was ineffective in 32 patients (12.6%). Stent dysfunction that caused symptom recurrence during follow-up developed in 46 patients (16.6%). Adverse events occurred in 49 patients (17.7%). Three or more stenosis sites (odds ratio [OR] = 6.11; P .01) and Karnofsky performance scores ≤50 (OR = 6.63; P .01) predicted clinical ineffectiveness. Karnofsky performance scores ≤50 predicted stent dysfunction (hazard ratio [HR] = 3.63; P .01). Bile duct stenosis (HR = 9.55; P = .02) and liver metastasis (HR = 9.42; P .01) predicted stent overgrowth. Covered stent predicted stent migration (HR = 12.63; P .01). Deployment of 2 stents predicted perforation (HR = 854.88; P .01).Through-the-scope gastroduodenal stenting tended to be ineffective in patients with poor performance status and long stenosis sites. Stent dysfunction occurred more frequently in patients with poorer performance status. Deployment of 2 stents was a risk factor for perforation. Identification of these risk variables may help yield better gastroduodenal stenting outcomes.

There is a growing body of evidence that a pathological diagnosis is necessary for small (3 cm in diameter), asymptomatic, hypoechoic, subepithelial tumors (SETs) originating from the muscularis propria on EUS. However, the diagnostic efficacy of current tissue sampling techniques appears to be limited.To evaluate the diagnostic yield and safety of endoscopic partial resection using the unroofing technique (EPR-UT) in a subset of patients.A prospective case series.A single tertiary-care referral center.Between August 2007 and March 2009, 16 patients with hypoechoic SETs of3 cm in diameter, originating from the muscularis propria on EUS (14 gastric and 2 esophageal lesions), underwent EPR-UT.The overlying mucosa was removed by using the unroofing technique using a conventional snare with electrical current to expose the tumor sufficiently. Next, the exposed tumor was partially resected by snaring.The diagnostic yield and safety of this method.EPR-UT provided specimens that were sufficient for a diagnosis and the assessment of risk for malignancy in 15 out of 16 cases (diagnostic yield 93.7% [95% CI, 80.4%-100.0%]). The pathological diagnoses were leiomyoma (7 of 15, 46.6%), GI stromal tumor (6 of 15, 40.0%), aberrant pancreas (1 of 15, 6.6%), and well-differentiated neuroendocrine carcinoma (1 of 15, 6.6%). Six cases with GI stromal tumor were classified as very low risk for malignant potential (mitotic index5/50 high-power fields). Procedural blood oozing was relatively common (9 of 16, 56.0% [95% CI, 33.0%-77.0%]); however, this minor complication was easily controlled by argon plasma coagulation. There were no procedure-related major complications (0 of 16, 0% [95% CI, 0.0%-23.0%]).Single-center, noncomparative study with small sample size.EPR-UT appears to be simple, safe, and effective for determining the definite pathological diagnosis and assessing malignant potential of small, hypoechoic SETs originating from the muscularis propria on EUS.

Background Self-expandable metal stents (SEMSs) are an effective palliative treatment for malignant biliary or duodenal strictures, but endoscopic stenting for combined malignant biliary and duodenal obstruction remains technically difficult. Objective To evaluate the feasibility and clinical success rate of endoscopic double stent-in-stent placement by using a new duodenal metallic stent for the management of malignant biliary and duodenal obstructions. Design Prospective, observational clinical feasibility study. Setting Tertiary referral center. Main Outcome Measurement Technical and clinical success, complications, midterm outcome. Patients and methods Eight patients with inoperable malignant biliary and duodenal strictures were enrolled. Endoscopic placement of a biliary SEMS was performed through the mesh of the duodenal stent. Results The duodenal strictures were in the first part of the duodenum in 3 patients (type 1) and in the second part in 5 patients (type 2). Duodenal stents were successfully deployed in all patients. Endoscopic placement of a biliary SEMS through the mesh of the duodenal stent was successful in 7 (87.5%) of 8 patients. In 2 of 3 patients with type 2 duodenal strictures with failed bile duct cannulation, biliary stenting was successful by using the rendezvous procedure. Early complications occurred in 1 patient. The overall median survival after combined stenting was 91 days (range 36–314 days). Limitations Small number of patients and no comparison with other enteral stents. Conclusions Biliary stenting through the new duodenal metallic stent is technically feasible and has a high success rate. Combined endoscopic biliary and duodenal stent-in-stent placement is a promising solution for the palliation of malignant biliary and duodenal obstruction.

Duodenal stent placement has emerged as an effective and safe palliative treatment for patients with malignant gastroduodenal obstruction. An uncovered enteral stent, however, is susceptible to repeat stenosis because of tumor ingrowth. Although covering an enteral stent with a membrane prevents tumor ingrowth, stent migration continues to be a major unresolved problem. Partially covered metal stents may avoid both tumor ingrowth and stent migration.To evaluate the clinical and technical efficacy and the safety of a partially covered duodenal stent for malignant gastroduodenal obstruction.Retrospective, observational study.Tertiary-care medical center.Twenty patients with malignant gastroduodenal obstruction received palliative treatment with partially covered duodenal stents.Endoscopic stent placement.Technical success, clinical success, patency, and adverse events.Stent placement was successful in all 20 patients (technical success rate, 100%), and symptoms improved in 19 (clinical success rate, 95%). The Gastric Outlet Obstruction Scoring System score improved significantly (P .001). Eight patients (40%) developed tumor overgrowth, whereas none showed stent migration. Median stent patency was 79.5 days (range 13-198 days). Adverse events occurred in 3 patients, including 2 with transient bacteremia and 1 with asphyxia because of impaction of food material into the stent.Single center, retrospective design, and a small number of patients.Partially covered duodenal stents were effective and safe for malignant gastroduodenal obstruction and may prevent tumor ingrowth and stent migration.

Background This study evaluated the efficacy and the complications associated with the use of the covered Wallstent in the setting of unresectable malignant biliary obstruction. Methods Between March 2001 and January 2003, all patients with distal malignant biliary obstruction that required drainage were treated with a covered Wallstent. Every 2 months, the patients were evaluated clinically and biochemical tests of liver function were obtained. Data were recorded for the following variables: early complications (within 30 days of stent placement), early and late stent occlusion, duration of stent patency, need for subsequent biliary intervention, and patient survival. Results A total of 88 covered Wallstents were inserted in 80 patients. Stent patency rates at 3, 6, and 12 months were 90%, 82%, and 78%, respectively. Complications included stent migration (5), stent occlusion (12), episodes of cholecystitis (3), and episodes of post-ERCP pancreatitis (5). Biliary intervention was required in 9 patients subsequent to placement of the initial covered Wallstent. Conclusions Deployment of a covered Wallstent is safe and relatively easy. It achieves biliary drainage with an acceptable risk to benefit ratio in the majority of patients with distal malignant biliary obstruction.

Background Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible. Methods Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis. Results A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72]). Conclusions After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.

Background Studies on the clinical impact of EUS are lacking. The aim of this study was to examine the impact of EUS on the management plans by referring doctors and patient outcomes. Methods Consecutive patients undergoing EUS between August 2002 and June 2004 were prospectively studied. Referring doctors were given a pre-EUS questionnaire that asked about provisional diagnosis and management plan. A post-EUS questionnaire was sent 6 weeks after the procedure. Results A total of 330 patients were examined, and completed questionnaires were received in 70%. EUS-guided FNA was performed in 69 (30%) patients. EUS resulted in a change in diagnosis and management in 26% and 48% of cases, respectively. Thirty-nine of the latter patients (33%) avoided unnecessary surgery. In 50% of cases, additional investigations were avoided. Doctors reported EUS as very or moderately useful in 210 patients (91%). Doctors of 223 patients (97%) reported that they would use EUS again. Conclusions The use of EUS had a significant clinical impact on patients. EUS resulted in a change of diagnosis in a fourth of patients and a change in management in half of patients studied.

A decade has passed since the introduction of EUS-guided FNA (EUS-FNA), and 6 years have passed since the last technology assessment in this journal. Most major medical centers, especially those with significant oncologic patient populations, now have access to this procedure. EUS-FNA is now frequently incorporated into the management algorithms of patients with suspected mediastinal or abdominal neoplasms. The purpose of this review is to provide an evidenced-based assessment of EUSFNA.

Background: EUS has emerged as standard practice with respect to the diagnosis and staging of GI malignancies. Whether currently available resources are sufficient to meet the potential need for EUS is uncertain. This study examines the hypothetical demand for EUS in the United States. Methods: EUS cases performed at 3 centers with well-established expertise in EUS in 1997 were retrospectively reviewed and trends were extrapolated to national cancer statistics. Indications for EUS fell into 3 categories: (1) diagnosis/staging of esophageal, gastric, pancreatic, or rectal cancers (established indications); (2) suspected GI malignancy (obligate "rule out"); and (3) "other" (emerging indications). Hypothetical total numbers of cases in which EUS could be performed in the United States were calculated taking into consideration the expected number of GI malignancies for which EUS would be appropriate (based on cancer statistics for 2000), the fraction unresectable by CT, the fraction of elderly nonsurgical candidates, proportionate "rule out" cases, as well as "other" emerging indications. Results: The calculated hypothetical number of cases (United States) in which EUS would be indicated is 79,568 per year (10,287 esophagus, 10,666 stomach, 23,069 pancreas, and 35,546 rectal). If "other" indications remained constant at 12%, there would potentially be 89,116 EUS procedures performed per year, with a conservative estimate of 79,572 per year. Conclusions: This model suggests that currently available EUS resources are not sufficient to meet hypothetical demand. Future considerations include the number of endoscopy units in which EUS is performed, the capacity of individual units, and the implications for training programs in the United States. (Gastrointest Endosc 2002;55:328-34.)

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Thirty-eight consecutive patients underwent endoscopic ultrasound-guided fine-needle aspiration. Of 46 lesions, 34 were extraluminal (12 pancreatic masses, 8 periesophageal nodes, 6 celiac nodes, 2 pericolonic masses, 1 mediastinal mass, 1 perigastric mass, 1 liver, 1 periduodenal node, 1 perirectal mass, 1 perirectal node) and 12 were submucosal (8 gastric, 3 duodenal, 1 esophageal). One hundred sixty-three passes were made, with an average of 3.5 passes per lesion and 4.3 passes per patient (range, 1 to 8). Adequate specimens were obtained from 91% of targeted lesions. The overall diagnostic accuracy was 87%. In patients with malignant lesions, sensitivity was 91% and specificity 100%. Celiac nodes were successfully sampled and diagnostic in 5 of 6 (83%) patients. No complications occurred. Using this technique, an initial tissue diagnosis of malignancy was made in 66% of cancer patients without a previous diagnosis and the preoperative stage was changed in 44% of cancer patients. The additional information gained by this modality directly influenced the decision not to perform surgery in 26% of patients with a primary malignancy. Endoscopic ultrasound-guided fine-needle aspiration is feasible and can be safely used to evaluate submucosal and extraluminal lesions in both the upper and lower gastrointestinal tract with a high degree of diagnostic accuracy.

Percutaneous endoscopic gastrostomies are used most commonly for enteral feeding. We report the use of such gastrostomies for decompression of the obstructed gastrointestinal tract. Percutaneous endoscopic gastrostomies were performed on 53 patients over a 2-year period for gastrointestinal decompression because of gastric or small bowel obstruction. Forty-six patients had malignant obstruction from a primary abdominal or metastatic carcinoma and 7 patients had non-malignant obstruction or stasis. Gastrostomy for decompression was successful in 41 of 46 (89%) cases of malignant obstruction and in all 7 of the non-malignant cases. Tube utilization for decompression averaged 60 +/- 91 days. A 28 F tube with a 4-inch perforated intragastric portion was fashioned to maximize drainage. This efficient decompression tube allowed oral intake of liquids and soft foods in 88% of patients. Complications, which occurred in 4%, included one case of fatal peritonitis and one case of cellulitis.