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OBJECTIVE: The aim of this prospective study was to compare the feasibility, technical success rate and complication between single-step endo-ultrasonography (EUS)-guided and two-step EUS-guided drainage technique for symptomatic pancreatic pseudocyst (PP). METHODS: Twenty-one PP patients with clear intra-cystic fluid that needed to be drained were divided into two groups, depending on the availability of the therapeutic echoendoscope at the time of the procedure: Group 1 (13 patients) underwent a single-step EUS-guided endoscopic drainage and Group 2 (8 patients) underwent a two-step EUS-guided drainage technique. RESULTS: In Group 1 immediate technical success was achieved in 92.3% (12/13); two patients had recurrent PP and both were successfully treated by a second EUS-guided drainage. Clinical success was achieved in all cases. In Group 2 technical success was achieved in 75.0% of the patients (6/8). One patient (12.5%) bled 36 h after the procedure. Five out of 6 patients had long-term success. Clinical success was significantly greater in Group 1 (P < 0.05). CONCLUSION: The technique of single-step EUS-guided drainage was superior to the technique of a two-step EUS-guided drainage technique for PP drainage.

Ascaris lumbricoides is the second most common intestinal parasite world-wide and, although the infection can be asymptomatic, in some cases it can present with complications, such as acute pancreatitis.We describe the case of a 37-year-old man, with a history of travelling in Eastern countries who presented with Ascaris lumbricoides-induced acute pancreatitis mimicking a small pancreatic cancer, diagnosed during an upper EUS. The endoscopy revealeda roundworm floating in the duodenum; its endoultrasonographic appearance showed a diffuse inhomogeneous pattern, with hypoechoic echotexture, such as in acute pancreatitis. Microbiological examination of the worm revealed a 20 cm long Ascaris lumbricoides.In non endemic countries, acute pancreatitis induced by Ascaris lumbricoides is an unusual diagnosis, and should be suspected especially in patients with history of traveling in endemic areas.

Atrophic gastritis (AG), first step in the cascade leading to gastric adenocarcinoma, is related to Helicobacter pylori (H. pylori) infection. Currently, the gold standard for the diagnosis of AG is esophagogastroduodenoscopy (EGD) with histological examination of the biopsy specimens. However, since the latter are taken in random order and the distribution of AG is often patchy, histology is only representative of mucosal status. Considering this limitation, a test named GastroPanel®, that measures the blood concentrations of pepsinogen I and II, gastrin-17 and H. pylori antibodies, has been developed as a potential non-invasive biopsy. Aim of this study has been to assess the accuracy of GastroPanel® in patients with AG.Forty-seven dyspeptic patients (24 males, mean age 52.2±9.3 years), in follow-up for antral or diffuse AG, were enrolled. All underwent at least two EGDs with random biopsies and blood collection for GastroPanel® parameters examination.Of the 47 patients, 16 (34.1%) had histological diagnosis of antral and 31 (65.9%) multifocal AG; 17 (36.2%) patients had mild and 30 (63.8%) had moderate-severe AG. H. pylori was detected in 39 (82.9%) and intestinal metaplasia was found in all patients. GastroPanel® showed 82.9% sensitivity for the diagnosis of AG and 53.8% for the diagnosis of H. pylori infection. The prediction of advanced atrophy was not sufficiently accurate, neither in patients with antral nor in those with multifocal AG.GastroPanel® can be useful for detecting patients with AG. However, it does not reflect the severity of atrophy.

Background Endoscopic ultrasound (EUS)-guided tissue acquisition represents the choice of methods for suspected lymph nodes (LNs) located next to the gastrointestinal tract. This study aimed to compare the pooled diagnostic performance of EUS-guided fine-needle biopsy (EUS-FNB) and fine-needle aspiration (EUS-FNA) for LNs sampling. Methods We searched PubMed/MedLine and Embase databases through August 2021. Primary outcome was diagnostic accuracy; secondary outcomes were sensitivity, specificity, sample adequacy, optimal histological core procurement, number of passes, and adverse events. We performed a pairwise meta-analysis using a random-effects model. The results are presented as odds ratio (OR) or mean difference along with 95% confidence interval (CI). Results We identified nine studies (1,276 patients) in this meta-analysis. Among these patients, 66.4% were male; the median age was 67 years. Diagnostic accuracy was not significantly different between the two approaches (OR, 1.31; 95% CI, 0.81–2.10; P = 0.270). The accuracy of EUS-FNB was significantly higher when being performed with newer end-cutting needles (OR, 1.87; 95% CI, 1.17–3.00; P = 0.009) and in abdominal LNs (OR, 2.48; 95% CI, 1.52–4.05; P Conclusions EUS-FNA and EUS-FNB perform similarly in LN sampling; however, FNB performed with end-cutting needles outperformed FNA in terms of diagnostic accuracy.

Pancreatic neuroendocrine tumor (PNET) behavior assessment is a daily challenge for physicians. Modern PNET management varies from a watch-and-wait strategy to surgery depending on tumor aggressiveness. Therefore, the aggressiveness definition plays a pivotal role in the PNET work-up. The aggressiveness of PNETs is mainly based on the dimensions and histological grading, with sometimes a lack of specificity and sensibility. In the last twenty years, EUS has become a cornerstone in the diagnostic phase of PNET management for its high diagnostic yield and the possibility of obtaining a histological specimen. The number of EUS applications in the PNET work-up has been rapidly increasing with new and powerful possibilities. The application of contrast has led to an important step in PNET detection; in recent years, it has been gaining interesting applications in aggressiveness assessment. In this review, we underline the latest experiences and opportunities in the behavior assessment of PNETs using contact-enhanced EUS and contested enhanced harmonic EUS with a particular focus on the future application and possibility that these techniques could provide.

There is scarce evidence on the comparison between different methods for the drainage of distal malignant biliary obstruction (DMBO) after endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we performed a network meta-analysis to compare the outcomes of these techniques. We searched main databases through September 2021 and identified five randomized controlled trials. The primary outcome was clinical success. The secondary outcomes were technical success, overall and serious adverse event rate. Percutaneous trans-hepatic biliary drainage was found to be inferior to other interventions (PTBD: RR 1.01, 0.88–1.17 with EUS-choledochoduodenostomy (EUS-CD); RR 1.03, 0.86–1.22 with EUS-hepaticogastrostomy (EUS-HG); RR 1.42, 0.90–2.24 with surgical hepaticojejunostomy). The comparison between EUS-HG and EUS-CD was not significant (RR 1.01, 0.87–1.17). Surgery was not superior to other interventions (RR 1.40, 0.91–2.13 with EUS-CD and RR 1.38, 0.88–2.16 with EUS-HG). No difference in any of the comparisons concerning adverse event rate was detected, although PTBD showed a slightly poorer performance on ranking analysis (SUCRA score 0.13). In conclusion, all interventions seem to be effective for the drainage of DMBO, although PTBD showed a trend towards higher rates of adverse events.

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Background and Aim: Celiac disease (CD) is a common condition but often it goes unrecognized because characteristic histopathological abnormalities must be found to confirm the diagnosis. A way is needed to select patients who need biopsy of the duodenal mucosa to detect CD. No data are currently available on the use of in vivo optical coherence tomography (OCT), during real-time endoscopic imaging, in the small intestine and, particularly, in the diagnosis of CD. The aim of the present study was to test the utility of OCT in patients undergoing esophagogastroduodenoscopy (EGD) for histological diagnosis. Methods: Eighteen patients with suspected CD (positive for antigliadin, antiendomysial and antitransglutaminase antibodies) and 22 dyspeptic subjects (negative for these antibodies) who were also examined by EGD, were prospectively enrolled. OCT scans of descending duodenum were taken during diagnostic EGD, with biopsies of the same duodenal area. OCT images and histological specimens were evaluated blindly, analysis being done independently by a gastroenterologist and a pathologist. Three patterns of intestinal villous morphology were considered (1, no atrophy; 2, mild atrophy; 3, marked atrophy). Results: Concordance was total between OCT and histology for villi morphology in both patients and normal subjects. Conclusions: OCT appears to be a promising method for correctly identifying villous atrophy; it may help in selecting patients for intestinal biopsies, considering the limited usefulness of endoscopic criteria, and may also help the endoscopist to perform target biopsies in mucosal areas where the villi are damaged or absent, considering that CD often causes patchy mucosal lesions.

Background and study aims. Optical coherence tomography permits high-resolution imaging of tissue microstructures by a probe inserted into the main pancreatic duct through a standard ERCP catheter. The aim of this study was to compare optical coherence tomography images of the main pancreatic duct with histology and identify the optical coherence tomography pattern of the normal and pathological structure of the main pancreatic duct. Patients and methods. Multiple sections of neoplastic and non-neoplastic segments of 10 consecutive surgical pancreatic specimens obtained from patients with pancreatic head adenocarcinoma were investigated by optical coherence tomography scanning within I h of resection. One hundred optical coherence tomography findings were then compared with the corresponding histopathological diagnoses. Results. Main pancreatic duct wall architecture appeared at optical coherence tomography investigation as a three-layer structure with a different back-scattered signal from each layer. Optical coherence tomography imaging was concordant with histology in 81.8% and 18.75% of sections with normal tissue and chronic inflammatory changes. The K statistic between the two procedures was equal to 0.059 for nonneoplastic main pancreatic duct wall appearance. In all neoplastic sections optical coherence tomography showed a subverted layer architecture with heterogeneous back-scattering of the signal and was concordant with histology. Conclusions. Optical coherence tomography provided images of main pancreatic duct wall structure that were concordant with histology in 100% of cases in presence of neoplastic ductal changes and did not have false-positive or negative results. Optical coherence tomography images were also concordant with histology in about 80% of cases with normal main pancreatic duct structure; however, the differential diagnosis between normal tissue and chronic pancreatitis or dysplastic changes appeared very difficult. (c) 2006 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. ZR 0 ZS 0 ZB 1 Z8 1

Background Endoscopic mucosal resection (EMR) is an effective therapeutic technique well-standardized worldwide for the treatment of gastrointestinal neoplasm limited to the mucosal layer. To date, no study has compared technical and clinical differences based on the number of EMRs performed per year. This study aimed to compare EMR technical success, complications, and clinical outcome between low-volume centers (LVCs) and high-volume centers (HVCs). A total of nine endoscopic centers were included in the study. Methods This prospective study investigated consecutive patients with sessile polyps or flat colorectal lesions 1 cm or larger referred for EMR. Results A total of 427 lesions were resected in 384 patients at nine endoscopic centers. Males accounted for 60.4 % and females for 39.6 % of the patients. Most of the EMRs (84.8 %) were performed in HVCs and only 15.2 % in LVCs. All the lesions were resected in only one session. Argon plasma coagulation was performed on the margins of piecemeal resection in 15.7 % of the patients in HVCs only. Complete excision was achieved for 98.6 % of the lesions in HVCs and 98.8 % of the lesions in LVCs. The complication rate was 4.4 % in HVCs and 4.6 % in LVCs (p = 0.94). Delayed bleeding occurred in 2.5 % of the HVC cases and 3.1 % of the LVC cases. Perforation occurred in 1.9 % of the HVC cases and 1.5 % of the LVC cases (p = 1.00). Recurrences were experienced with 15 % of the lesions: 15.5 % in HVCs and 14 % in LVCs (p = 0.79). Conclusions The study showed that EMR can be performed also in LVC.

Optical coherence tomography (OCT) is an optical imaging modality introduced in 1991 that performs high-resolution, cross-sectional, subsurface tomographic imaging of the microstructure in materials and biologic systems by measuring backscattered or backreflected infrared light. OCT has been used for biomedical applications where many factors affect the feasibility and effectiveness of any imaging technique. The highly scattering and absorbing living tissues greatly limit the application of optical imaging modalities. In the last decade, OCT technology has evolved from an experimental laboratory tool to a new diagnostic imaging modality with a wide spectrum of clinical applications in medical practice, including the gastrointestinal (GI) tract and pancreaticobiliary ductal system.

Aims: To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units. Methods: A prospective study using a questionnaire (Group Health Association of America—9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload. Results: In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days. Conclusion: It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure.

Background Type 1 sphincter of Oddi dysfunction is a clinical entity characterised by biliary-type pain, elevated liver biochemical tests, and common bile duct dilation. Sphincter fibrosis is a common finding in this type of dysfunction and may require in some cases a differential diagnosis with a malignant intra-papillary disease. Optical coherence tomography permits high-resolution, real-time imaging of the sphincter of Oddi microstructure by a probe inserted into the common bile duct through an ERCP catheter. No data exist on the evaluation of sphincter of Oddi fibrosis by optical coherence tomography during ERCP in vivo. Objective To assess the feasibility of optical coherence tomography investigation of the sphincter of Oddi structure and assess its potential for diagnosing type 1 sphincter of Oddi dysfunction. Patients Ten consecutive patients, five with biliary-type 1 sphincter of Oddi dysfunction and five with pancreatic head/mid-body adenocarcinoma not involving the papillary region, who underwent both endoscopic ultrasound and therapeutic ERCP, were investigated by optical coherence tomography immediately before biliary sphincterotomy or stenting. Results In all sphincter of Oddi dysfunction patients optical coherence tomography recognised a hyper-reflective intermediate, fibro-muscular layer, significantly thicker than in patients with non-pathological sphincter of Oddi (p Conclusions Optical coherence tomography imaging recognised an increased thickness and reflectance of the fibro-muscular layer of the sphincter of Oddi, very likely determined by fibrosis, and was not time-consuming; it can be safely used during ERCP to confirm the diagnosis in difficult cases. Its use in clinical practice has one important limitation since it requires magnification in the post-procedure computer analysis to obtain images useful for diagnosis.

Background: Self-expanding metal stents (SEMSs) are used to treat malignant stenosis of the gastrointestinal (GI) tract, as a safe, feasible, and minimally invasive option for reestablishing luminal patency. However, the literature offers scant prospective data on the clinical outcome of these patients. Aim: To assess the technical success, complications, and clinical outcomes of patients with a SEMS placed for malignant upper and lower GI obstruction. Patients and Methods: A cohort of 110 patients with clinical symptoms related to malignant stenosis of the upper and lower GI tract were prospectively enrolled and SEMSs were placed endoscopically in 9 endoscopy centers. The patients were followed up and survival, oral intake, stool canalization, and late complications were recorded on days 30, 90, and 180. Results: Overall, 110 patients, 38 (34.5%) with upper and 72 (65.5%) with lower GI obstruction were examined. The procedure was successful in 102 (92.7%). There were 5 early complications ( 96h) occurred in 6 patients (6.3%). Median survival after stenting was 90 days (ql 30; q3 120). Placing the SEMS enabled 79.4%, 90.9%, and 100% of the patients to resume an oral diet at 30, 90, and 180 days, respectively. All patients had stool canalization until death. Conclusions: Endoscopic stenting is an effective and safe procedure for malignant luminal obstruction of the GI tract, with good clinical outcomes in patients whose survival is unfortunately short.

BACKGROUND Optical coherence tomography (OCT) permits high-resolution imaging of tissue microstructures using AND STUDY a probe that can be inserted into the main pancreatic duct (MPD) through a standard endoscopic AIMS: retrograde cholangiopancreatography (ERCP) catheter. This prospective study was designed to assess the diagnostic capacity of OCT to differentiate between nonneoplastic and neoplastic lesions in patients with MPD segmental strictures. PATIENTS Twelve consecutive patients with documented MPD segmental stricture were investigated by AND METHODS: endoscopic ultrasonography (EUS), with fine-needle aspiration cytology if necessary, and ERCP, followed by brush cytology and OCT scanning. RESULTS: OCT recognized a differentiated three-layer architecture in all cases with normal MPD or chronic pancreatitis, while in all the neoplastic lesions the layer architecture appeared totally subverted, with heterogeneous backscattering of the signal. The accuracy of OCT for detection of neoplastic tissue was 100% compared with 66.7% for brush cytology. In one case, neither OCT scanning nor brush cytology was possible because of the severity of the stricture. CONCLUSIONS: This pilot study showed that OCT is feasible during ERCP, in cases of MPD segmental stricture, and was superior to brush cytology in distinguishing nonneoplastic from neoplastic lesions.

Optical coherence tomography (OCT) permits high-resolution, real-time, infrared-generated imaging of tissue microstructures by a probe inserted through the endoscope operative channel. Resolution is approximately 10 microm and the penetration depth of the near-focus probe is about 1 mm. The probe can be inserted into the main pancreatic duct (MPD) through a standard endoscopic retrograde cholangiopancreatography catheter.To assess the ability of OCT to identify the structure of the MPD, to distinguish normal and malignant MPD epithelium, and to assess intra- and interobserver reproducibility of OCT images. Multiple sections of neoplastic and non-neoplastic segments of 10 consecutive surgical pancreatic specimens were obtained from patients with pancreatic head adenocarcinoma who had undergone Whipple resection, and repeated OCT radial and longitudinal scanning was done within 1 h of resection and before pathological examination. We compared 249 good-quality images with 100 histopathological sections.OCT recognized a definite, different pattern in 82.9% of tumor-free and in 97.6% of tumor-involved specimens; sensitivity and specificity for discrimination between adenocarcinoma and normal tissue were 78.6% and 88.9%, respectively. Inflammatory and dysplastic changes of the MPD showed an OCT pattern similar to that of the normal tissue in 53.3% of images. Overall, intraobserver reproducibility ranged from 85.1% to 100% and interobserver reproducibility ranged from 69.9% to 100% and from 89.7% to 100% for tumor-free and tumor-involved segments, respectively.OCT identified the neoplastic and non-neoplastic MPD layer structure and appeared to be a reproducible technique. In non-neoplastic conditions, OCT appeared unable to differentiate between normal and abnormal tissues in about half of the cases.

OBJECTIVES: To evaluate the short- and long-term efficacy of self-expanding metal stents (SEMSs) in patients with colorectal obstruction and incurable cancer and the related factors that affect outcomes. DESIGN: Retrospective analysis of SEMS placement for incurable colorectal obstruction in a 3-year period. SETTING: Five tertiary care endoscopic centers. PATIENTS AND INTERVENTION: Consecutive patients (N = 201) undergoing stenting for incurable malignant obstruction. MAIN OUTCOME MEASUREMENTS: Clinical and technical success of stenting, complications rate, and factors affecting outcomes. RESULTS: Technical success was achieved in 184 of 201 patients (91.5%) and clinical success occurred in 165 of 184 patients (89.7%; 82.1% of 201 patients). Technical and clinical failures were more frequent in extrinsic and long colorectal stenoses. Overall, 165 patients had normal bowel movements during follow-up (mean [SD], 115.5 [100.3] days; range, 1-500 days), 15 developed complications, 127 had a functioning SEMS at the time of death, and 23 were alive at completion of the study. Twenty-four (11.9%) major complications occurred: 11 migrations, 12 perforations, and 1 reobstruction. Migration of SEMSs was associated with stent diameter less than 25 mm. Bevacizumab therapy increased the risk of perforation by 19.6-fold. Karnofsky performance status of 50 or less was associated with shorter survival and a 3.7-fold higher risk of death within 6 months after the stent was placed. CONCLUSIONS: The use of SEMSs is safe and effective for palliation of incurable malignant colonic obstruction; approximately 75% of patients with SEMSs are able to avoid colostomy.

ilatation (with Savary); now the patient is in remission. Two patients (3–4 ears old) have no more symptoms, the EGD is normal, but they are still on ietary treatment. The last two patients are still on medical treatment. Conclusions. In patients with eosinophilic oesophagitis the pH-metry is ormal, the anti-acid therapy is useless and the oesophageal biopsy shows high number of eosinophils (>20/HPF). The differential diagnosis is with astro-oesophageal reflux, allergies, eosinophilic gastroenteritis, parasites nfections, gastrointestinal disorders (coeliac and Crohn disease). The surical approach is necessary only in few cases when there are also other athologies. GER is present in 10% of patients with EE.

Background: Gallstone disease is characterized by an impaired gallbladder (GB) emptying and a reduced GB turnover of bile, being the latter assessed by a mathematical analysis of UltraSonographic (US) data (1). In these patients administration of ursodeoxycholic (UDCA) acid seems to be associated to a reduced risk of bifiary pain and complications. The effect of UDCA on GB function is still matter of debate. Aim: To assess by means of statistical analysis of the US motility data, and GB bile flow with computer fluid dynamics the effect of UDCA therapy. Patients and Methods: in 3 GS patients, postprandial US assessment of GB volumes, for a study period of 90 minutes, with a time sampling of 1 minute, has been performed before and after 30 days of UDCA therapy (lOmg/Kg/die). The measured time series were successively analyzed with statistical tools and Fourier analysis. Results: The average volume of the gallbladder of patients is increased upon UDCA treatment (10.6%, 21.1%, 23.9%, respectively). The increase is statistically significant for the three patients. Indeed, a hypothesis test (a T-test) on the means of two distributions led to the conclusions that, with 95% significance, the null hypothesis of equal mean volumes pre and posttreatment must be rejected for the three patients. On the other hand, the organ motility is only slightly affected by UDCA administration, so that the characteristic GB-dimension oscillations remain essentially unaltered. In particular, the time series analysis shows that the volume oscillations have the same amplitude before and after UDCA treatment, and a Fourier analysis shows that also the characteristic frequencies (pre and post treatment) are basically unchanged. A simple geometrical reasoning proves that UDCA treatment improves the intra-GB bile turnover. Conclusions: Short-time treatment with UDCA induces an improvement of postprandial GB bile exchanges in GS patients. Application of standard statistical tests and time series analysis in the frequency domain to US GB motility data could provide additional insights into the assessment of intra-GB bile stasis, a key-event in the pathogenes is of GS disease. 1) M.Cicala et al. U l t rasound Med Blot 2001 Nov;27(11):1445-50.