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Although transgastric endoscopic ultrasound (EUS)-guided biopsy is a safe and accurate method for sampling of the left adrenal gland, only 2 reports describing EUS-guided fine-needle aspiration (FNA) of the right adrenal gland have been published to date. The aim of this series was to report 2 additional successful cases of EUS-FNA of right adrenal masses.In this retrospective single-center case series, prospectively updated cytology and EUS databases between January 1997 and September 2007 were reviewed to identify all patients who underwent attempted EUS-FNA of either adrenal gland. Those who underwent EUS-FNA of the right adrenal gland were identified and reviewed.Of 52 consecutive patients who underwent EUS-FNA of either adrenal gland, 2 had attempted biopsy of the right adrenal gland and constituted the study population. The first patient had a history of colon cancer and was found to have a right adrenal mass during workup of jaundice. The second patient also had a history of colon cancer and was found to have an enlarging right adrenal mass and a subcarinal mass during follow-up computed tomography. Endoscopic ultrasound-guided FNA showed a pheochromocytoma in the first patient and metastatic colon cancer in the second patient. No complications were encountered during either procedure.This series further shows that EUS-FNA of right adrenal masses is feasible and may be an option for sampling of these lesions. Prospective studies comparing EUS with percutaneous FNA of adrenal masses are indicated to help delineate the indications and limitations of each technique.

Background and study aims Solid pseudopapillary tumors of the pancreas are rare, low-grade, epithelial neoplasms that are usually discovered incidentally in young women. Distinguishing solid pseudopapillary tumors from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this context remains unclear. The purpose of this study was to describe the endoscopic ultrasound features of solid pseudopapillary tumors and the role of EUS-FNA in the preoperative diagnosis of these tumors. Patients and methods Patients from five tertiary referral centers with surgically confirmed solid pseudopapillary tumors who had undergone preoperative EUS-FNA were included. The endoscopic ultrasound findings, cytologic descriptions, immunostaining results, operative records, surgical pathology, and results of the most recent clinical follow-up were reviewed. Results A total of 28 patients were identified (four men [14 %], 24 women [86 %], mean age +/- standard deviation [SD] 35 +/- 10 years). Solid pseudopapillary tumors had been found as incidental findings on cross-sectional imaging in 50 % of cases. The mean tumor size +/- SD was 42 +/- 19.5 mm and the majority were located in the pancreatic body and tail. The endoscopic ultrasound report described a well-defined, echo-poor mass in 86 %; the tumors were solid in 14 patients (50 %), mixed solid and cystic in 11 patients (39 %), and cystic in three patients (11 %). A preoperative diagnosis of solid pseudopapillary tumor was made in 21 patients (75 %) on the basis of EUS-FNA cytology. Surgical resection was performed in all cases. Laparoscopic resection was performed in eight of these patients (29 %). Conclusions A solid pseudopapillary tumor should be included in the differential diagnosis of any well-demarcated, echo-poor, solid or mixed solid/cystic pancreatic lesion seen during endoscopic ultrasound, particularly in young women. The diagnostic accuracy of EUS-FNA for solid pseudopapillary tumors was 75 % in this study. A definitive preoperative diagnosis can guide the surgical approach in selected cases.

Background & Aims: The aim of this study was to see if a 170° angle of view (wide angle [WA]) colonoscope allowed faster withdrawal without decreasing adenoma detection. Methods: Eight colonoscopists at 2 institutions participated in the study. Patients were randomized so that each colonoscopist performed 50% of the exams with a 160 series (140° angle of view; standard [ST]) colonoscope and 50% with a prototype 160 series colonoscope with a 170° angle of view (WA instrument). Insertion and withdrawal times and number of polyps detected were recorded. Endoscopists were asked to withdraw as quickly as they could carefully complete the exams. Analysis of variance was done to compare insertion and withdrawal times and number of polyps detected. Time to perform biopsy, polypectomy, and cleaning was subtracted using a stopwatch. Results: A total of 710 procedures were performed, 355 with ST and 355 with WA colonoscope. The mean insertion time was similar. The mean withdrawal time (absent time for suctioning, washing, etc.) with the WA colonoscope was 4.9 min which was shorter (4.9 vs 5.4 min; P = .0001) overall and for three individual endocopists (P = .0001, P = .01, and P = .03). There was no difference in the mean number of adenomas detected per colonoscopy with ST (0.6) compared to WA (0.5) (P = .12). Two of the three endoscopists with shorter withdrawal times with WA had numerically higher detection rates with WA. Conclusions: The WA colonoscope is associated with a reduction in withdrawal time without compromising adenoma detection. However, this effect is operator dependent and the overall impact of wide-angle optics in this study was minor.

Bispectral index monitoring (BIS) is a quantitative assessment of brain cortical activity. The aim of this study was to determine if BIS-guided nurse-administered propofol sedation would decrease by > or = 20% both recovery time and propofol dose compared to standard propofol sedation for endoscopic ultrasound (EUS). Prospectively, eligible outpatients were randomized to BIS-guided or standard propofol sedation during EUS. Propofol was given by nurses in intermittent boluses with sedation targeted at a BIS score of < 65-75. For the control group, the nurse was blinded to BIS scores and sedation was titrated to a modified observer's assessment of alertness/sedation scale (MOAA/S) score < or = 3. Of 50 patients enrolled, data for 44 randomized to BIS-guidance (n = 24) and the control group (n = 20) were evaluated. Between the BIS-guided and control group there was no difference between the mean procedure duration, total propofol dose, recovery time, mean intraoperative MOAA/S, and mean BIS score. Compared to standard propofol sedation for EUS, BIS-guided propofol sedation offers no significant decrease in postprocedure recovery times or propofol doses.

OBJECTIVE. The objective of this article is to discuss the CT findings that guide surgeons in deciding the feasibility of tumor excision in patients with locally advanced pancreatic head cancers.CONCLUSION. Vascular resection as an adjunct to pancreaticoduodenectomy is increasingly used in pancreatic head cancer. As a result, the imaging criteria to determine which patients are candidates for potentially curative resection are evolving.

Endoscopic ultrasound (EUS) with EUS-guided fine needle aspiration (EUS-FNA) has been increasingly utilized to differentiate malignant/pre-malignant pancreatic cysts from those that are benign or have low malignant potential.To determine the utility of EUS morphology, EUS-FNA cytology and cyst fluid analysis to distinguish mucinous cystic neoplasms from non-mucinous cystic neoplasms based on histopathology following surgical resection.A retrospective, single center case series.Patients who underwent EUS and EUS-FNA of known or suspected pancreatic cysts followed by surgical resection. The final diagnosis was based on histopathology.Patients were divided in two groups: mucinous cystic neoplasms and non-mucinous cystic neoplasms. Patients with intraductal papillary mucinous tumors were excluded.Clinical profiles and EUS findings.Forty-eight patients (mean age: 52 years; 29 females, 19 males) were identified: 16 mucinous cystic neoplasms and 32 non-mucinous cystic neoplasms. There were more women in the mucinous cystic neoplasm group compared to the non-mucinous cystic neoplasm group (88% vs. 47%; P=0.011) but the two groups were otherwise similar. The sensitivity, specificity and frequency of cases correctly identified of EUS-FNA cytology for the diagnosis of mucinous cystic neoplasms were 12.5% (95% CI: 2.2-37.2%), 90.6% (95% CI: 75.0-97.5%) and 64.6% (95% CI: 50.4-77.0%), respectively. Median cyst fluid CEA for the mucinous cystic neoplasm group (277 ng/mL; n=14) was significantly higher (P=0.002) than the non-mucinous cystic neoplasm group (1.5 ng/mL; n=21). Cyst fluid CEA greater than 800 ng/mL had a sensitivity of 42.9% (95% CI: 21.3-67.4%) and specificity of 95.2% (95% CI: 75.6-99.9%) for the diagnosis of mucinous cystic neoplasm. On the other hand, a cyst fluid CEA greater than a best cut-off ranging from 3.5 to 8.5 ng/mL had a sensitivity of 92.9% (95% CI: 66.5-100%), a specificity of 66.7% (14/21; 95% CI: 45.2-83.0%), and an accuracy of 81.1% with a frequency of cases correctly identified of 77.1% (95% CI: 60.7-88.2%).EUS-FNA cytology and cyst fluid CEA greater than 800 ng/mL are insensitive but highly specific for differentiating mucinous cystic neoplasms from non-mucinous cystic neoplasms. EUS morphology alone cannot distinguish between the two groups.

OBJECTIVE. The purpose of our study was to review how commonly performed radiologic examinations compare with capsule endoscopy in the investigation of small-bowel diseases, to analyze the limitations of capsule imaging, and to propose an algorithm for use of specific radiologic examinations to complement wireless capsule endoscopy.CONCLUSION. The diagnostic yield of capsule endoscopy is superior to that of radiologic examinations except air double-contrast enteroclysis for mucosal details. Radiologic investigations find new applications in clinical practice by complementing capsule endoscopy to overcome its limitations.

Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fine-needle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3 + 0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short- and long-term outcomes after resection are excellent.

Background The utility of a repeated EUS by experts is not known. Objective To define the utility of a repeated EUS for the same indication. Design A retrospective case series. Setting Tertiary-referral hospital in Indianapolis, Indiana. Patients Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital. Interventions A repeated EUS. Main Outcome Measurements Clinical impact of a repeated EUS. Results Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed. Limitations A retrospective design; a small number of nonpancreatic indications. Conclusions In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Current management of intraductal papillary mucinous neoplasm (IPMN) according to recently published International Consensus Guidelines depends upon distinguishing it from mucinous cystic neoplasms (MCNs). We have previously shown that prostaglandin E(2) (PGE(2)) is increased in pancreatic cancer tissue over normal controls. Thus, we hypothesized that PGE(2) level in pancreatic fluid differentiates IPMN and MCN and is a biomarker of IPMN dysplasia. Pancreatic fluid was collected in 65 patients at the time of endoscopy (EUS or ERCP) or operation (OR) and analyzed by PGE(2) enzyme-linked immunosorbent assay (ELISA). PGE(2) level was correlated with surgical pathologic diagnosis and dysplastic stage. Mean PGE(2) level (pg/microl) in IPMNs (2.2 +/- 0.6) was greater than in MCNs (0.2 +/- 0.1) (p0.05). Mean PGE(2) level of IPMN by dysplastic stage was 0.1 +/- 0.01 (low grade), 1.2 +/- 0.6 (medium grade), 4.4 +/- 0.9 (high grade), and 5.0 +/- 2.3 (invasive). Among invasive IPMN, PGE(2) level dropped in advanced cases with pancreatic ductal obstruction by tumor (0.3 +/- 0) vs non-obstructed (8.6 +/- 2.9). PGE(2) level may help in distinguishing IPMN from MCN in patients with known mucinous lesions. PGE(2) level may also be an indicator of malignant progression of IPMN before ductal obstruction by tumor. Prospective evaluation will be necessary to evaluate the clinical role of PGE(2) level in pancreatic fluid.

Background and study aim Although the left adrenal gland is readily visible by endoscopic ultrasound (EUS), there are few published data on the utility of EUS-guided fine-needle aspiration (EUS-FNA) of this site. The aim of this study was to report our experience of EUS-FNA of left adrenal gland masses. Patients and methods In this retrospective case series, we reviewed our EUS and cytology databases to identify consecutive patients who underwent EUS-FNA of the left adrenal gland between January 1997 and January 2004. Medical records were reviewed and the results of EUS examinations and cytological investigations were abstracted. Results Our searches resulted in the identification of a series of 38 consecutive patients who underwent EUS for the evaluation of a lung mass (n = 14), a pancreatic mass (n = 14), obstructive jaundice (n = 1), dysphagia (n = 2), an ampullary adenoma (n = 1), celiac block (n = 1), or a left adrenal gland mass (n = 5). The mean maximal left adrenal mass diameter was 24 mm (range 7-66 mm). Diagnoses after EUS-FNA (the mean number of passes was 3.6) were: metastatic lung cancer (n = 2), esophageal adenocarcinoma (n = 1), melanoma (n = 1), renal cell carcinoma (n = 1), and pancreatic neuroendocrine tumor (n = 1); primary pheochromocytoma (n = 1); benign adrenal tissue (n = 21); and granulomatous inflammation (n = 1). Nine aspirations (24 %) were nondiagnostic. The absence of a discrete adrenal mass on EUS occurred more frequently in patients with nondiagnostic biopsies than in those with diagnostic biopsies (56 % vs. 7 %; odds ratio 23.4, 95 %CI 3.5 - 157.0; P = 0.004). No complications were noted. Conclusions EUS-FNA of the left adrenal gland is safe and can be useful for the evaluation and staging of suspected malignancy. Nondiagnostic biopsies are more common when sampling diffusely enlarged glands, compared with glands with a focal mass.

Figure 1. SharkCore FNB Needle. Tu1639 EUS-Guided Fine Needle Tissue Acquisition Using a Nitinol Ultra Flex 19-Gauge Needle for Transduodenal Lesions: a Multicenter Prospective Study Alberto Larghi*, Carlo Fabbri, Ichiro Yasuda, Laurent Palazzo, Ilaria Tarantino, John M. Dewitt, Lorenzo Fuccio, Leonardo Frazzoni, Fabia Attili Digestive Endoscopy Unit, Catholic University, Rome, Italy; Department of Gastroenterology, AUSL Bologna Ospedale Bellaria-Maggiore, Bologna, Italy; Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan; Trocadero Clinic, Paris, France; Endoscopy Unit, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy; Department of Gastroenterology, Indiana University Medical Center, Indianapolis, IN; Department of Surgical and Medical Sciences, Sant’Orsola Hospital, University of Bologna, Bologna, Italy Background and Aim: EUS-guided fine needle biopsy (EUS-FNB) using 19G needles to obtain core biopsy tissue samples may be difficult when performed transduodenally. Recent data on a limited number of patients have suggested that a new nitinol 19-gauge needle (Expect 19 Flex needle, Boston Scientific Corp, Natick, MA, USA) can improve the performance of EUS-FNB from the duodenum. Aim of this study was to determine the feasibility, diagnostic yield and accuracy of EUS-FNB with the nitinol ultra flex 19-gauge needle for lesions approached from the duodenum. Methods: This is a multicenter prospective study performed in 6 tertiary referral centers. Patients with solid lesions, which needed transduodenal EUS-FNB were considered eligible. The EUS-fine needle tissue acquisition technique, in which the stylet is removed before inserting the needle in the working channel of the echoendoscope to increase needle flexibility was used in all cases. Three needle passes were attempted in all patients with the Expect 19G Flex needle. In case of failure the use of another needle was at the discretion of the endoscopist. Technical success rate, diagnostic yield and accuracy were the primary endpoints. Safety and assessment of difficulty of needle use were the secondary endpoints. Results: Up to now, 172 cases have been included (mean age 66 13 years, 38% females): 143 were pancreatic or peripancreatic mass lesions and 29 were lymph nodes (mean size 33.1 12.4mm), 59.9% of which were approached from the duodenal bulb and the remaining from the second (37.2%) or third (2.9%) duodenal portion. FNA was technically feasible in 156 lesions (90.7%) and an adequate histological sample was obtained in 132 cases (76.7%). Considering malignant vs. non-malignant diseases, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 65.8% (95%CI 57.7-73.1), 100% (95%CI 75.9-100), infinity and 0.34 (95% CI 0.270.43), respectively, yielding an overall diagnostic accuracy of 68.6%. Five major complications were reported (3 cases of bleeding, 1 perforation and 1 acute pancreatitis). The needle use was judged easy in 63.1% and 62.2% of cases for lesions approached from the bulb and from the second/third duodenal portion, www.giejournal.org Vol respectively (pZ0.767). Conclusion: Our multicenter prospective study demonstrated that EUS-FNTA using the new nitinol 19G Flex for sampling mass lesions through the duodenum is technically successful in most cases, but diagnostic yield and accuracy are suboptimal. Tu1640 The Cellularity Yield of Three Different 22-Gauge Endoscopic Ultrasound Fine Needle Aspiration (FNA) Needles Mohamed O. Othman*, Osvaldo Padilla, Sherif Elhanafi, Sheri Fallin, Claudia Acuna, Mohamed Eloliby, Alireza Torabi, Nawar Hakim, Darius A. Boman Internal Medicine/Gastroenterology, Texas Tech University HSC at El Paso, Houston, TX; Gastroenterology, Baylor College of Medicine, Houston, TX; Pathology, Texas Tech University HSC at El Paso, El Paso, TX Background: Endoscopic Ultrasound (EUS-FNA) is an integral part in diagnosis of pancreatic, intestinal and extra-intestinal masse s or lesions. Different sizes and shapes of needles are available. The 22-gauge needle is the most commonly used needle. The aim of this study is to prospectively compare the cellularity yield of three most commonly used 22-gauge FNA needles currently available in the US market. Methods: This is a prospective, randomized study comparing the cellularity yield of the following 22-gauge EUS FNA needles: EZ Shot 2 “EZ” (Olympus America Inc., Center Valley, PA), Expect “EX” (Boston Scientific Natick, MA) and ProCore “PC” (Cook Endoscopy, Winston-Salem, NC). Randomization was done using sealed opaque envelopes. Two blinded pathologists evaluated the cytology specimens based on an already agreed upon cytology score. One non-blinded endoscopist performed the procedure. One pathologist was present during the procedure and he determined the need for extra passes. Adult patients (18 to 80 yrs) who presented to our endoscopy unit for FNA of pancreatic and extra pancreatic lesions were included. Results: 109 patients (57 F, 52 M) were recruited to the study. Mean age of patients was 61.2 years old. 39 patients in the EZ shot group, 34 in the EX group and 36 in the PC group. 88 lesions were pancreatic and 21 lesions were extrapancreatic. Number of passes (SD) was not different between the EZ, EX, PC needles: 2.46 (1.21), 3.06 (1.43) and 2.67 (1.37) respectively( PZ 0.163). Diagnosis was obtained onsite in 70.6% of cases. There was no difference between the three needles in ability to obtaining diagnosis on site (PZ0.627). Overall cellularity scores, neoplastic cellularity score, quantity of blood cells score, cellular debris and amorphous material score and inflammatory score were not different between the three needles. Table 1. Cross over to another needle (either for failure to obtain diagnosis or due to mechanical problems) was noted in 20% of cases done with EZ needle compared to 5.8 % of EX and 5.5 in PC needle (P!0.08). Complications were similar between the three groups. Conclusion: The cellularity yield of three of the most commonly used EUS FNA 22-gauge needles was similar. There was a tendency toward crossing over to another needle when using EZ needle but this tendency did not reach a statistical significance.

Mo1484 Endoscopic Ultrasound (EUS) Is Superior to Esophagogastroduodenoscopy (EGD) and Esophageal Capsule Endoscopy (ECE) for Varices Screening Tsion Abdi*, Danielle Marino, Avlin B. Imaeda, Chuhan Chung, Petr Protiva, Anil B. Nagar Digestive Diseases, Yale University School of Medicine, New Haven, CT; Digestive Diseases, West Haven VA, West Haven, CT; Gastroenterology, University of Rochester, Rochester, NY Background: EGD is the standard of care for the diagnosis of esophageal varices while esophageal capsule endoscopy (ECE) is an accepted alternative. Prior studies have not evaluated endoscopic ultrasound (EUS) compared to EGD and ECE in screening for esophageal varices. Aim: To compare the performance of EGD, ECE, and EUS in diagnosing esophageal varices. Methods: A single center prospective blinded study of consecutive patients with cirrhosis referred for variceal screening. Patients underwent three procedures at one visit. ECE with PillCam was performed first and followed by EGD under conscious sedation. An EUS was then done using a TTS 20MHZ probe performed by a different endoscopist. ECE consultant was blinded to the results of the other procedures. Varices were graded as following: EGD small v/s large, ECE small v/s large and EUS by measuring size in mm. SPSS software was used to calculate sensitivity, specificity, predictive value and compare groups for agreement. Results: 52 patients were enrolled in the study. 48 patients completed all three tests. Four patients were excluded due to inability to perform all three tests due to dysphagia, food in stomach and inability to sedate. The mean age was 60 and the average MELD score was 10.8 (range of 7 to 20). Varices were detected by EUS, EGD and ECE in 44, 32, and 38 patients, respectively. Using EUS as a gold standard EGD had a sensitivity of 72.7%, specificity 100%, positive predictive value 100% and negative predictive value 25% respectively. ECE had a sensitivity 79.5%, specificity 25%, positive predictive value 92% and negative predictive value of 10% respectively. The kappa value for agreement between EUS and EGD was .308, denoting fair agreement. The kappa value for agreement between EGD and ECE was .483, denoting fair agreement. The kappa value for agreement between EUS and ECE was .027, denoting poor agreement. EUS varices size was!2mm in 17 patients, between 2mm and 3mm in 18 patients and O3mm in 9 patients. Both EGD and ECE identified!50% of the varices less than 2 mm in size on EUS compared to 85% of varices more than 2 mm in size on EUS (p value equals!.009). Procedures were safe with few complications, 1 patient had bleeding post EGD and 2 patients experienced aspiration with ECE. Conclusions: This study prospectively identifies EUS as the most sensitive test to screen for varices. Further studies are necessary to determine if finding on EUS may reflect changes in early clinically compensated portal hypertension. Mo1485 Comparison of Direct Endoscopic Injection (DEI) and EUS-Guided Fine Needle Injection (EUS-FNI) of 2-Octyl-Cyanoacrylate for Treatment of Gastric Varices Ji Young Bang*, Mohammad A. Al-Haddad, Michael V. Chiorean, Naga P. Chalasani, Paul Y. Kwo, Marwan Ghabril, Marco A. Lacerda, Saurabh Agrawal, Howard Masouka, Raj Vuppalanchi, Eric S. Orman, Margaret S. Sozio, Samer Gawrieh, Craig Lammert, Suthat Liangpunsakul, John M. Dewitt Gastroenterology-Hepatology, Indiana University, Indianapolis, IN; Gastroenterology & Hepatology, Cleveland Clinic, Abu Dhabi, United Arab Emirates; Digestive Diseases institute, Virginia Mason Medical Center, Seattle, WA Background: Gastric varices (GV) can bleed in 10-70% of patients and are associated with significant morbidity and mortality. Endoscopic therapy with 2-octyl cyanoacrylate (CYA) may be performed by direct endoscopic injection (DEI) or more recently by fine needle injection (FNI) under EUS guidance. However, impact of EUS-guided FNI of GV compared to DEI is unknown. Aim: To compare the incidence of rebleeding and adverse events associated with DEI and EUS-FNI of CYA for GV. Methods: Consecutive patients at a single tertiary hospital who underwent DEI with CYA for primary prophylaxis or active/recent GV bleeding between 2/ 2006 and 4/2012 were initially identified. These patients represent our initial experience with endoscopic therapy of GV. To improve outcomes, DEI was abandoned in 2012 in favor of EUS-FNI. Results of FNI using CYA between 1/2013 and 9/2014 for the same patient population were prospectively recorded. Patient characteristics, procedure details and outcomes between the two groups were analyzed. Primary outcome: rate of GV rebleeding %30 (early) or O30 days after (late) therapy. Secondary outcomes: 1) no. of treatments needed for GV eradication; 2) incidence of adverse events (AEs). DEI and EUS-FNI were performed with 23 gauge and 19 gauge needles respectively, in 0.5-1.5mL aliquots. No coils were used. In the absence of early rebleeding, follow-up endoscopy and possible repeat therapy in both groups were performed within 3 months and periodically thereafter to eradicate GV. Eradicated GV: 1) direct endoscopy showed no visible GV or 2) residual GV were hardened on catheter palpation or exhibited minimal/ absent flow by Doppler EUS. AEs were classified as mild, moderate or severe (Cotton P et al., GIE 2012). Results: 31 patients underwent EUS-FNI (38 injecwww.giejournal.org Vol tions) and 40 received DEI (53 injections). Patient demographics and procedure findings/outcomes are listed in the Table. There was no significant difference in overall incidence of GV rebleeding after EUS-FNI (nZ2; 7.7%) and DEI (nZ9, 23.7%; 16.0% [95% CI 0-32.5] for the difference in rebleeding rate between the treatment groups). Early GV rebleeding occurred in both EUS-FNI patients and 6 of 9 DEI patients. Recurrent all-cause GI bleeding was higher in DEI group (57.9 vs. 22.6%, pZ0.004). Overall AEs were significantly higher in EUS-FNI group (47.4 vs. 13.2%, p!0.001), however the incidence of moderate/severe AEs (2 PEs, 2 splenic infarcts in EUS-FNI; 4 bleeding during injection in DEI) were similar. Conclusions: CYA injection of GV by both endoscopic and EUS approaches appear to be safe and effective with similar high treatment success rates. Both techniques may lead to rare, potentially serious AEs. Further studies are needed to determine the long-term impact of EUS-FNI in the treatment of GVs. Comparison of FNI and DEI groups ume 81, No. 5S : 2015 G EUS (n[31) ASTROINTESTI DEI (n[40) NAL ENDOSCOPY p-value Age (years) Median (IQR) 58 (46-67) 57 (52.5-60) 0.885 Gender (n, %) Female 14 (45.2) 11 (27.5) 0.122 Etiology of GV (n, %) Cirrhosis 26 (83.9) 38 (95.0) 0.227 Other 5 (16.1) 2 (5.0) Etiology of cirrhosis (n, %) Hepatitis C 9 (34.6) 12 (31.6) 0.920 Alcohol 5 (19.2) 8 (21.1) NASH/Cryptogenic 8 (30.8) 14 (36.8) Other 4 (15.4) 4 (10.5) MELD Median (IQR) 13 (9-15) 16.5 (12-22) 0.024 Reason for eradication (n, %) Primary prophylaxis 5 (16.1) 2 (5.0) 0.227 Secondary prophylaxis Active bleeding 1 (3.2) 5 (12.5) Stigmata 10 (32.3) 25 (62.5) GV type (n, %) IGV1 15 (48.4) 3 (7.5) !0.001 GOV1 2 (6.5) 6 (15.0) GOV2 14 (45.2) 30 (75.0) Largest GV size (mm) Median (IQR) 10 (7-13) 10 (10-12) 0.144 CYA volume injected (mL) Median (IQR) 2 (1.5-3) 3 (3-3) !0.001 No. of sessions for eradication 1 24 (77.4) 30 (75.0) 0.346 2/3 7 (22.6) 10 (25.0) Follow-up (days) Median (IQR) 238 (95-378) 362 (110.5-946.5) 0.123 GV rebleed (n, %) Overall 2 (7.7) 9 (23.7) 0.176 Early 2 (7.7) 6 (15.8) Late 0 3 (7.9) All cause GI bleed (n, %) Overall 7 (22.6) 22 (57.9) 0.004 Early 5 (16.1) 10 (26.3) Late 2 (6.5) 12 (31.6) Adverse events (n, %) Overall 18 (47.4) 7 (13.2) !0.001 Mild 14 (36.8) 3 (5.7) 0.156 Moderate/Severe 4 (10.5) 4 (7.5) Mo1486 The Diagnostic Utility of Endoscopic Ultrasonography in Assessing the Depth of Tumor Invasion in Early Gastric Cancer Fang Yao*, Aiming Yang, Dongsheng Wu, Xi Wu, Tao Guo, Weixun Zhou, Xinghua Lu Gastroenterology, Peking Union Medical College Hospital, Beijing, China; Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China Objective: To evaluate the role of endoscopic ultrasonography (EUS) in assessing the depth of tumor invasion in early gastric cancerand and to analyze the factors affecting the accuracy of EUS. Methods: This retrospective study enrolled 59 cases of histologically confirmed early gastric cancer who received pre-treatment EUS for

266 Background: Endoscopic retrograde cholangiopancreatography (ERCP) with brushing/fluid sampling has historically been the standard to establish invasive transformation of pancreatic head intraductal papillary mucinous neoplasm (IPMN). More recently, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) has been employed for this purpose. We hypothesized that for patients with invasive IPMN, in the era of EUS FNA, there is no additional benefit of ERCP brushing/fluid sampling. Methods: A retrospective review of a prospectively maintained database of patients who underwent surgical resection for IPMN at a single academic center (1992-2014) was performed. Patients with invasive pancreatic head IPMN on surgical pathology were included. Cytopathology was considered positive if it showed adenocarcinoma or markedly atypical cells. Results: Of the 74 patients with invasive IPMN, 55 had a pancreatic head neoplasm. Preoperatively, 4 patients had neither EUS nor ERCP, 27 had only 1 endoscopic study (ERCP n=16, EUS n=11), and 24 had both EUS and ERCP. In 11 patients with EUS, 8 had positive FNA (73% sensitivity for cancer detection). In 16 patients with ERCP (brushing n=7, fluid n=9), 5 had positive cytology resulting in 31% sensitivity. Further analysis revealed 29% and 33% sensitivity for brushing and fluid sampling, respectively. When both procedures were performed (n=24; EUS+ERCP fluid n=10, EUS+ERCP brushing n=14), the sensitivity was 75%, but ERCP cytology changed the diagnosis in only 2 patients. EUS FNA was performed regardless of ERCP cytology results in 18 patients (after brushing n=6, after fluid sampling n=4, same day n=8; median interval=4 days). 6 patients had negative cytology from both EUS and ERCP. Conclusions: In patients with invasive pancreatic head IPMN, sensitivity of ERCP cytology for cancer detection was poor (31%), making an impact on diagnosis in only 2/55 patients. EUS FNA was performed in 75% patients regardless of ERCP cytology results. Aside from the therapeutic impact of ERCP (biliary endoprosthesis in jaundiced patients), its cytological role is limited, resulting in unnecessary and potentially avoidable cost.

Background & Aims: It is uncertain whether computed tomography (CT) or endoscopic ultrasound (EUS) is superior for the detection, staging, and resectability of pancreatic cancer. We therefore performed a systematic literature review to determine which test is more accurate. Methods: We identified relevant studies from MEDLINE (1986–2004) and evaluated study quality, which was measured on the basis of guidelines for assessing studies of diagnostic tests. Quantitative outcomes data were abstracted from the studies. Results: Eleven studies with 678 patients satisfied inclusion criteria. Nine studies assessed tumor detection, all of which concluded that the sensitivity of EUS was superior to CT. Four of 5 studies that assessed tumor staging accuracy and 5 of 8 that assessed nodal staging accuracy concluded that EUS was superior to CT. Among the 4 studies that assessed resectability, 2 showed no difference between EUS and CT, and 1 favored each modality. Three of 11 studies met all but one of the quality criteria. The most important and frequent study limitations were lack of a consecutive series of patients and biased patient selection for surgery. Quantitative comparisons among studies were precluded by differences in tumor staging classifications, surgical selection, CT and EUS techniques, and reporting of operating characteristics. Conclusions: The published literature comparing EUS and CT for preoperative assessment of pancreatic cancer is heterogeneous in study design, quality, and results. All studies have methodologic limitations that potentially affect validity. Prospective studies with state-of-the-art imaging are needed to further define the role of each test.

The dissociative sticking coefficient for C2H6 on Pt(111) has been measured as a function of both gas temperature (Tg) and surface temperature (Ts) using effusive molecular beam and angle-integrated ambient gas dosing methods. A microcanonical unimolecular rate theory (MURT) model of the reactive system is used to extract transition state properties from the data as well as to compare our data directly with supersonic molecular beam and thermal equilibrium sticking measurements. We report for the first time the threshold energy for dissociation, E0 = 26.5 +/- 3 kJ mol(-1). This value is only weakly dependent on the other two parameters of the model. A strong surface temperature dependence in the initial sticking coefficient is observed; however, the relatively weak dependence on gas temperature indicates some combination of the following (i) not all molecular excitations are contributing equally to the enhancement of sticking, (ii) that strong entropic effects in the dissociative transition state are leading to unusually high vibrational frequencies in the transition state, and (iii) energy transfer from gas-phase rovibrational modes to the surface is surprisingly efficient. In other words, it appears that vibrational mode-specific behavior and/or molecular rotations may play stronger roles in the dissociative adsorption of C2H6 than they do for CH4. The MURT with an optimized parameter set provides for a predictive understanding of the kinetics of this C-H bond activation reaction, that is, it allows us to predict the dissociative sticking coefficient of C2H6 on Pt(111) for any combination of Ts and Tg even if the two are not equal to one another.

The dissociative sticking coefficient for CH4 on Pt(111) has been measured as a function of both gas temperature (Tg) and surface temperature (Ts) using effusive molecular beam and angle-integrated ambient gas dosing methods. The experimental results are used to optimize the three parameters of a microcanonical unimolecular rate theory (MURT) model of the reactive system. The MURT calculations allow us to extract transition state properties from the data as well as to compare our data directly to other molecular beam and thermal equilibrium sticking measurements. We find a threshold energy for dissociation of E0 = 52.5 +/- 3.5 kJ mol(-1). Furthermore, the MURT with an optimized parameter set provides for a predictive understanding of the kinetics of this C-H bond activation reaction, that is, it allows us to predict the dissociative sticking coefficient of CH4 on Pt(111) for any combination of Ts and Tg even if the two are not equal to one another, indeed, the distribution of molecular energy need not even be thermal. Comparison of our results to those from recent thermal equilibrium catalysis studies on CH4 reforming over Pt nanoclusters ( approximately 2 nm diam) dispersed on oxide substrates indicates that the reactivity of Pt(111) exceeds that of the Pt nanocatalysts by several orders of magnitude.

Intramuscular injection of plasmid DNA expression vectors results in transfection of myocytes in situ. To determine whether expression of antigen by myocytes is sufficient to induce protective cell-mediated immunity, stably transfected myoblasts expressing influenza nucleoprotein (NP) were transplanted into mice. These animals produced high-titer anti-NP antibodies and MHC class I-restricted cytotoxic T lymphocytes, and were protected from a cross-strain lethal challenge with influenza A virus. Therefore, antigen expression by muscle cells in vivo is sufficient to confer protective cell-mediated immunity.

Background Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult. Objective To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP. Design Retrospective cohort study. Setting Single, tertiary referral hospital in Indianapolis, Indiana. Patients Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP. Interventions EUS-FNA of PBS. Main Outcome Measures Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up. Results A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively. Limitations Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery. Conclusions EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.

Diagnostic or therapeutic thoracentesis in patients with mechanical ventilation is typically performed with ultrasound guidance using a posterolateral approach.1 Recently, the use of endoscopic ultrasound (EUS) for detection and aspiration of pleural effusions2,3 and the feasibility of bedside EUS in critically ill patients has been described.4,5 We present a case of EUS-guided therapeutic thoracentesis performed at the bedside in a critically ill patient on mechanical ventilation. A 69-year-old female was admitted to our hospital with acute liver failure suspected to be secondary to drug toxicity. She was transferred to the intensive care unit because of worsening liver failure, hepatic encephalopathy, atrial fibrillation, fluid overload, and respiratory distress requiring intubation. Chest radiography (Fig. 1) and abdominal computed tomography revealed a large right pleural effusion, pancreatic mass and possible cirrhosis. She was not deemed a candidate for an urgent liver transplant because of the indeterminate pancreatic mass. Furthermore, systemic chemotherapy and radiation were not considered because of acute liver failure. Bedside EUS was requested by the intensive care unit team for both tissue diagnosis of the pancreatic mass and therapeutic thoracentesis to facilitate ventilation. Endoscopy was performed in a supine position while the patient was on mechanical ventilation. EUS revealed a 25×20 mm T2NxMx solid and cystic mass in the pancreatic body (Fig. 2), and fine needle aspiration (FNA) using a 22-gauge needle with on-site cytology review was consistent with adenocarcinoma. Therapeutic thoracentesis of the right-sided pleural effusion was then performed. The stylet was removed from a 19-gauge needle (Echotip; Wilson-Cook Endoscopy, Winston-Salem, NC, USA), and transesophageal puncture of the right pleural space was performed (Fig. 3). Fluid was removed by attaching tubing between the proximal end of the needle and a suction canister. A total of 2 L was removed without complications over a 30-minute period. The total procedure time was 70 minutes. Cytology from the pleural fluid was negative for malignancy, and the fluid was transudative. Hypoxemia improved following the procedure, and follow-up chest radiography showed no pneumothorax or worsening pulmonary edema. The patient's family was informed of the diagnosis of pancreatic malignancy. Based on the patient's previous written wishes, the confirmed diagnosis of malignancy and the liver failure, medical care was withdrawn 24 hours later, and the patient expired. Fig. 1 Large right pleural effusion observed using chest radiograph. Fig. 2 Solid and cystic mass in the pancreatic body. Fig. 3 Aspiration of right pleural space with 22-gauge needle. To our knowledge, this case represents the first report of EUS-guided therapeutic thoracentesis performed at the bedside in a critically ill patient on mechanical ventilation. Currently, there are limited data on the utility of EUS for thoracentesis3 and bedside EUS.4,5 Furthermore, only one case of EUS-guided therapeutic paracentesis has been described.6 EUS-FNA of pancreatic cyst fluid is traditionally performed using a 22- or 25-gauge needle with a 10-mL syringe attached to the proximal end for suction. Aspiration of large volumes of fluid using such a small needle and syringe would be time-consuming and impractical. Using a 19-gauge FNA needle attached to continuous suction, we were able to perform large-volume therapeutic thoracentesis in a fashion similar to that described in a previous report of EUS-guided therapeutic paracentesis.6 Thoracentesis was requested in our patient only because simultaneous EUS-FNA of a pancreatic mass was necessary. As percutaneous ultrasound-guided thoracentesis in patients on mechanical ventilation has been shown to be feasible and safe in patients without significant coagulopathy,1,7-9 we believe that EUS guidance should be considered only in cases in which EUS is required for another reason. Pleural effusions are commonly recognized in critically ill patients, and their management remains poorly standardized.9 Commonly cited reasons for drainage include diagnosis of infection, hypoxemia, excessive ventilator pressure or difficulty in weaning from mechanical ventilation. With the exception of established infection of the pleural space, the balance of risk and benefit of pleural drainage remains fairly controversial for each of these indications.9 Pleural drainage may improve hypoxemia or lung mechanics, but the physiological response depends on a complex interplay among lung and chest-wall compliance, applied positive expiratory pressure and drainage volume.9 In conclusion, EUS-guided therapeutic thoracentesis is feasible and may be considered when EUS is required for another indication or when the traditional posterior approach is not feasible.

Background Accurate preoperative detection and staging of pancreatic cancer may identify patients with locoregional disease that is amenable to surgical resection. Objective To compare endoscopic ultrasonography and multidetector computed tomography (CT) for the detection, staging, and resectability of known or suspected locoregional pancreatic cancer. Design Prospective, observational, cohort study. Setting Single, tertiary referral hospital in Indianapolis, Indiana. Patients 120 participants with known or suspected locoregional pancreatic cancer. Interventions Endoscopic ultrasonography followed by multidetector CT was performed in all patients. Patients with known or suspected pancreatic cancer deemed potentially resectable by 1 or both tests were considered for surgery. Measurements Detection, staging, and resectability of pancreatic cancer. Surgically resected pancreatic cancer with negative microscopic histologic margins was considered resectable. Results Of 120 patients enrolled, 104 (87%) underwent endoscopic ultrasonography and CT. Of the 80 patients with pancreatic cancer, 27 (34%) were managed nonoperatively, and 53 (66%) treated surgically had resectable (n = 25) or unresectable (n = 28) cancer. For the 80 patients with cancer, the sensitivity of endoscopic ultrasonography (98% [95% CI, 91% to 100%]) for detecting a pancreatic mass was greater than that of CT (86% [CI, 77% to 93%]; P = 0.012). For the 53 surgical patients, endoscopic ultrasonography was superior to CT for tumor staging accuracy (67% vs. 41%; P 0.2). Of the 25 resectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 88% and 92%, respectively, as resectable. Of the 28 unresectable pancreatic tumors in patients recommended for surgery, endoscopic ultrasonography and CT correctly identified 68% and 64%, respectively, as unresectable. Limitations Radiologists who read the scans and endosonographers were not blinded to previous radiographic information. Because of the modest sample size, CIs of the sensitivity estimates were sometimes wide. Conclusion Compared with multidetector CT, endoscopic ultrasonography is superior for tumor detection and staging but similar for nodal staging and resectability of preoperatively suspected nonmetastatic pancreatic cancer.

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512-1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Malignant melanoma is a neoplasm which originates from melanocytes. Surgical exploration for abdominal metastases of cutaneous melanoma reveals pancreatic metastases in 16 % of patients which is usually accompanied by other intra-abdominal spread. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) of primary and metastatic pancreatic masses have already been described. We report the first use of EUS-FNA for the diagnosis of malignant melanoma metastatic to the pancreas. As our cases illustrate, these lesions may present as either cystic or solid pancreatic masses. Preparation of a cell block from the FNA aspirate and use of immunostaining may help to obtain the diagnosis. Despite thorough examination of the skin and mucous membranes, however, a primary site might not be found in these patients.

Hydrolytically degradable, multilayered films ranging from 10 to 100 nm have been constructed by the layer-by-layer deposition of degradable polycations and oppositely charged polyanions. Polycations play dual roles in these systems, serving as structural components of the film as well as transient elements designed to trigger release; polyanions serve as structural components and as entities to be released or delivered. The films erode in a controlled manner under physiological conditions and are suitable for the incorporation and subsequent controlled release of functional polyanions such as DNA.

Corrigendum: American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Since the introduction of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA), EUS has assumed a growing role in the diagnosis and management of pancreatic ductal adenocarcinoma (PDAC). The objective of this review is to discuss the various applications of EUS and EUS-FNA in PDAC. Initially, its use for detection, diagnosis and staging will be described. EUS and EUS-FNA are highly accurate modalities for detection and diagnosis of PDAC, this high accuracy, however, is decreased in specific situations particularly in the presence of chronic pancreatitis. Novel techniques such as contrast-enhanced EUS, elastography and analysis of DNA markers such as k-ras mutation analysis in FNA samples are in progress and might improve the accuracy of EUS in the detection of PDAC in this setting and will be addressed. EUS and EUS-FNA have recently evolved from a diagnostic to a therapeutic technique in the management of PDAC. Significant developments in therapeutic EUS have occurred including advances in celiac plexus interventions with direct injection of ganglia and improved pain control, EUS-guided fiducial and brachytherapy seed placement, fine-needle injection of intra-tumoral agents and advances in EUS-guided biliary drainage. The future role of EUS and EUS in management of PDAC is still emerging.

Patients with pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) can develop abdominal pain that can be debilitating. Celiac plexus neurolysis (CPN) is a chemical ablation of the celiac plexus that can be used to treat pain caused by pancreatic malignancy. It can be performed by an anterior or posterior approach, and also can be done percutaneously or under guidance of transabdominal ultrasound, computed tomography, intra-operatively or most recently under linear endoscopic ultrasound (EUS) guidance (EUS-CPN). EUS is well-suited for identification of the celiac plexus due to the close proximity of the gastric wall to the origin of the celiac artery. EUS-CPN is now widely practiced, and different EUS approaches have been developed in order to improve the efficacy of this technique. Our objective is to review the use of EUS-CPN in PDAC, including a description of different techniques, review of its efficacy, predictors of pain response, and describe its limitations and safety, as well as new developments.