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BACKGROUND: Endoscopic submucosal dissection (ESD) was recently developed in Japan for en bloc removal of laterally spreading tumors (LSTs). Although initially used for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. Recent reports from Japan included removal of colorectal lesions up to 10 cm. OBJECTIVE: To show the feasibility of ESD to remove en bloc, very large LSTs of the rectum, even when there is involvement to the dentate line. DESIGN: Case report. SETTING: The procedure was performed at an American GI unit. The patient was admitted to the hospital after the procedure for observation. PATIENTS: A 53-year-old patient, with a 14-cm tubulovillous adenoma of the rectum, which, at its maximal extent, involved two thirds of the circumference of the rectum. The tumor extended distally to the dentate line. INTERVENTIONS: En bloc submucosal dissection with a conventional needle-knife to remove the neoplasm. MAIN OUTCOME MEASUREMENTS: Completeness of en bloc removal of the tumor and subsequent follow-up endoscopy that showed no residual neoplasm. RESULTS: The tumor was able to be removed en bloc by ESD. The distal margin included squamous mucosa. At a 2.5-week endoscopic follow-up, a 3-mm focus of residual polyp was seen and removed. At the time of the last follow-up, there was complete healing of the wound and no residual neoplasm. LIMITATIONS: Single case. CONCLUSIONS: This case demonstrated the feasibility of using ESD to remove large laterally spreading rectal tumors, including when there was involvement to the dentate line (and the dissection line must include squamous mucosa of the anal canal). ESD is a promising alternative to conventional surgical techniques; however, additional published experience is needed. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic submucosal dissection (ESD) is an internationally accepted technique for the resection of superficial gastrointestinal neoplasia. ESD allows for en-bloc removal when endoscopic mucosal resection (EMR) is unsuitable due to the size or depth of the lesion. The aim of this survey was to examine Canadian clinicians' experience and perceptions of ESD as its prevalence increases across the country., Methods: An electronic survey consisting of 24 multiple-choice questions was distributed via the Canadian Association of Gastroenterology email database and directly to those known to be performing or interested in ESD. The survey covered training, practice, obstacles in implementation, and perceptions of the future of ESD in Canada., Results: A total of 21 participants completed the survey. ESD was performed primarily in the endoscopy suite exclusively (71%), and most operators (64%) performed it on an outpatient basis. Procedure time was selected as the greatest technical challenge in the performance of ESD by 86% of the participants. Both lack of formalized training and long procedure times were the highest ranked barriers to the adoption of ESD. Over the next 5 years, 95% believed there would be an increase in ESD volume in Canada, and 43% believed ESD was ready for adoption by more therapeutic endoscopists., Interpretation: In this survey, we explored the current practice, attitude, and challenges of ESD in the Canadian landscape. As the performance of ESD increases and gains more acceptance across Canada, there are opportunities to address technical challenges and barriers through the formalization of training, education, and practice guidelines., (© 2021 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP., (Copyright © 2014 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Squamous cell carcinoma of the pancreas is a rare pancreatic malignancy. We describe the case of a female who presented with abdominal pain and was found to have a pancreatic mass on imaging. The diagnosis of pancreatic squamous cell carcinoma was established by endoscopic ultrasound-guided fine needle aspiration of the mass. To the best of our knowledge, this is only the second case report in the medical literature in which endoscopic ultrasound-guided fine needle aspiration was used for a cell-type specific diagnosis of primary pancreatic squamous cell carcinoma.

Background: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results., Objective: We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis., Design: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency., Setting: Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis., Patients: Adult patients undergoing ERCP., Interventions: Pancreatic stent placement for the prevention of post-ERCP pancreatitis., Main Outcome Measurements: Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement., Results: Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies., Limitations: Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement., Conclusions: Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Rectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied., Aim: To evaluate the accuracy of EUS in T0 staging of rectal cancers. METHOD (STUDY SELECTION CRITERIA): Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa. DATA COLLECTION AND EXTRACTION: Articles were searched in Medline, PubMed, and CENTRAL., Statistical Method: Pooling was conducted by both the fixed-effects model and random-effects model., Results: An initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (N = 1,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7-99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3-97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3-29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04-0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10., Conclusions: EUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47-85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51-64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.

Aim: To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection (EMR)., Methods: Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources., Results: An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies (n = 5221) which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% (95% CI: 51.50-73.52). The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% (95% CI: 47.14-69.71). With higher patient load (> 200 patients), this complete cure en-bloc resection rate improves from 44.19% (95% CI: 24.31-65.09) to 69.17% (95% CI: 51.11-84.61)., Conclusion: EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.

Background: Endoscopic submucosal dissection (ESD) has emerged as one of the techniques to successfully resect large colonic polyps en bloc. Complete resection prevents the patient from going through transabdominal colonic resection. We sought to evaluate the proportion of successful en-bloc and complete cure en-bloc resection of large colonic polyps by ESD., Methods: Studies that use ESD technique to resect large colonic polyps were selected. Successful en-bloc resection was defined as resection of the polyp in one piece. Successful complete cure en-bloc resection was defined as one piece with histologic disease-free-margin polyp resection. Articles were searched in Medline, PubMed, and Cochrane control trial registry. Pooled proportions were calculated by both fixed and random-effects model., Results: The initial search identified 2,120 reference articles; 389 relevant articles were selected and reviewed. Data were extracted from 14 studies (n = 1,314) that met the inclusion criteria. The mean +/- standard error size of the polyps was 30.65 +/- 2.88 mm. Pooled proportion of en-bloc resection by the random-effects model was 84.91% (95% confidence interval, 77.82-90.82) and complete cure en-bloc resection was 75.39% (95% confidence interval, 66.69-82.21). The fixed-effects model was not used because of the heterogeneity of studies., Conclusions: ESD should be considered the best minimally invasive endoscopic technique in the treatment of large (>2 cm) sessile and flat polyps because it allows full pathological evaluation and cure in most patients. ESD offers an important alternative to surgery in the therapy of large sessile and flat polyps.

Background: Nodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent., Aim: To evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers., Method: Study Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL., Statistical Method: Pooling was conducted by both fixed-effects model and random-effects model., Results: The initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (N = 2732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6-75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5-78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16-3.72), and negative likelihood ratio was 0.42 (95% CI 0.33-0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10., Conclusions: EUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Background: Published data on the accuracy of endoscopic ultrasound (EUS) for staging distant and celiac axis lymph node (CLN) metastasis in patients with esophageal cancer (ECA) has varied., Aim: To evaluate the accuracy of EUS in diagnosing distal and CLN metastasis in ECA patients., Study Selection: EUS studies confirmed by surgery were selected., Statistical Method: Pooling was conducted by both fixed and random-effects models., Results: Data were extracted from 25 studies (N = 2029) which met the inclusion criteria. In ECA patients, pooled sensitivity of EUS was 67.2% (95% CI: 62.6-71.6) in diagnosis of distal metastasis and 66.6% (95% CI: 61.9-71.1) in diagnosis of CLN metastasis. EUS had a pooled specificity of 97.9% (95% CI: 97.1-98.6) for distal metastasis and 98.1% (95% CI: 97.3-98.7) for CLN metastasis., Conclusions: Although EUS has excellent specificity in accurately diagnosing distal and CLN metastasis in patients with ECA, the sensitivity is low.

Aim: To evaluate the accuracy of endoscopic ultrasound (EUS) for staging of gastric cancers., Methods: Only EUS studies confirmed by surgery were selected. Only studies from which a 2 x 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing and allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane control trial registry. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 x 2 tables were constructed with the data extracted from each study. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights., Results: Initial search identified 1620 reference articles and of these, 376 relevant articles were selected and reviewed. Twenty-two studies (n=1896) which met the inclusion criteria were included in this analysis. Pooled sensitivity of T1 was 88.1% (95% CI: 84.5-91.1) and T2 was 82.3% (95% CI: 78.2-86.0). For T3, pooled sensitivity was 89.7% (95% CI: 87.1-92.0). T4 had a pooled sensitivity of 99.2% (95% CI: 97.1-99.9). For nodal staging, the pooled sensitivity for N1 was 58.2% (95% CI: 53.5-62.8) and N2 was 64.9% (95% CI: 60.8-68.8). Pooled sensitivity to diagnose distant metastasis was 73.2% (95% CI: 63.2-81.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was >0.10., Conclusion: EUS results are more accurate with advanced disease than early disease. If EUS diagnoses advanced disease, such as T4 disease, the patient is 500 times more likely to have true anatomic stage of T4 disease.

Aim: To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy., Methods: Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 multiply 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights., Results: Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI: 82.9-86.4) to 88.0% (95% CI: 85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI: 83.2-85.9) to 96.4% (95% CI: 95.3-97.4). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10., Conclusion: EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.

Aim: To evaluate the accuracy of endoscopic ultrasound (EUS) in the staging of esophageal cancer., Methods: Only EUS studies confirmed by surgery were selected. Articles were searched in Medline and Pubmed. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights., Results: Forty-nine studies (n = 2558) which met the inclusion criteria were included in this analysis. Pooled sensitivity and specificity of EUS to diagnose T1 was 81.6% (95% CI: 77.8-84.9) and 99.4% (95% CI: 99.0-99.7), respectively. To diagnose T4, EUS had a pooled sensitivity of 92.4% (95% CI: 89.2-95.0) and specificity of 97.4% (95% CI: 96.6-98.0). With Fine Needle Aspiration (FNA), sensitivity of EUS to diagnose N stage improved from 84.7% (95% CI: 82.9-86.4) to 96.7% (95% CI: 92.4-98.9). The P value for the c2 test of heterogeneity for all pooled estimates was > 0.10., Conclusion: EUS has excellent sensitivity and specificity in accurately diagnosing the TN stage of esophageal cancer. EUS performs better with advanced (T4) than early (T1) disease. FNA substantially improves the sensitivity and specificity of EUS in evaluating N stage disease. EUS should be strongly considered for staging esophageal cancer.

Background: Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks., Design: Observational, descriptive., Patients: Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation., Interventions: Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy., Main Outcome Measurements: Gallbladder access and visualization, stone clearance, symptom relief, and complications., Results: The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later., Limitations: Proof of concept performed in a single patient., Conclusions: Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.

Background and Aims: Our aim was to assess the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in an ambulatory endoscopy center (AEC)., Methods: Complications occurring in consecutive patients undergoing ERCP or EUS from March 2003 to February 2004 at our AEC were recorded prospectively. Comprehensive complications were defined as consensus criteria plus other adverse events: use of reversal agents, unplanned hospital admission, hospitalization beyond planned 23-hour observation, unplanned emergency department or primary care provider visit, and 30-day mortality., Results: A total of 497 patients (median age, 57 y; 82% American Society of Anesthesiologists class II or III) underwent 685 procedures. Monitored or general anesthesia was used in 25% of EUS and 50% of ERCP procedures. ERCP interventions were as follows: biliary or pancreatic stenting (N = 168), stone extraction (N = 70), sphincterotomy (N = 62), sphincter of Oddi manometry (N = 53), other (N = 66). EUS indications were as follows: known or suspected pancreatic mass (N = 103), upper-gastrointestinal mass/submucosal lesion (N = 71), luminal malignancy staging (N = 40), other (N = 96); 52% had EUS fine-needle aspiration. There was follow-up evaluation in 94% of the patients. There were 43 comprehensive ERCP complications (12.9%), 18 (5.4%) of these fit consensus criteria: pancreatitis (N = 14), cholangitis (N = 2), and perforation (N = 2). There were 9 comprehensive EUS complications (2.9%), 2 (.7%) of these fit consensus criteria: pancreatitis (N = 1) and bleeding (N = 1). Other adverse events for ERCP and EUS were as follows: prolongation of 23-hour observation (N = 14), emergency room visits (N = 3), primary care physician visits (N = 6), use of reversal agents (N = 3), unplanned admissions (N = 2), infection (N = 3), and death (N = 1)., Conclusions: ERCP and EUS can be performed in an AEC, provided mechanisms for admission and anesthesia support are in place. The assessment of comprehensive complications is more reflective of adverse events related to ERCP and EUS than consensus criteria alone.

Background: Single-step EUS-guided transmural drainage of pseudocysts has been reported, but there are no published prospective studies on clinical outcomes., Objective: To assess the safety and the efficacy of single-step EUS-guided placement of large endoprostheses to treat simple and complicated pseudocysts., Design: Prospective cohort study., Setting: Single tertiary referral center., Patients: Consecutive patients referred for management of symptomatic chronic pancreatic pseudocysts >4 cm in size., Interventions: Single-step EUS-guided transmural pseudocyst drainage performed with a linear-array echoendoscope for placement of 10F stents in adults and 7F stents in children., Main Outcome Measures: Complete or partial (>50% reduction) resolution of pseudocyst on follow-up imaging, recurrence, clinical response, and procedure-related complications. Recurrence was defined as the reappearance of a pancreatic pseudocyst in the same location., Results: There were 33 patients, with a mean age of 43 years. Median pseudocyst size was 8.5 cm (range, 4-20 cm). Fourteen patients (42%) had infected pseudocysts, 8 patients (24%) had gastric varices, and 16 patients (48%) had no visible endoscopic bulge. Stent placement was successful in 31 patients (94%). Twenty-seven patients (82%) had complete resolution of a pseudocyst; 4 patients (12%) had partial resolution, with symptom relief. There were 2 major complications and 3 minor complications. Recurrence of a pseudocyst was observed in only 1 patient over a median follow-up of 46 weeks., Limitations: No randomized treatment arm comparing this technique with conventional endoscopic drainage., Conclusions: Single-step EUS-guided transmural drainage with large endoprostheses is a safe and effective therapy for patients with simple and complicated pancreatic pseudocysts.

Objectives: Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here., Methods: A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004., Results: Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics., Conclusion: Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

Objectives: Assess the role of cholangioscopy in primary sclerosing cholangitis for 1) detection of cholangiocarcinoma using cholangioscopy-assisted biopsy 2) detection of stones not seen on cholangiography 3) stone removal with cholangioscopy-directed lithotripsy., Methods: Prospective cohort of consecutive patients referred for cholangioscopy to evaluate dominant strictures or stones. A data collection sheet was employed. Follow-up was by chart review/phone contact. Clinical improvement was defined as resolution of jaundice or > or =50% reduction in pain or cholangitis episodes requiring hospitalization., Results: 41 patients (30M, 11F) had 60 cholangioscopy procedures (55 per oral, 5 percutaneous). 33/41 (80%) patients underwent 44 tissue sampling events., Histology: positive for extrahepatic cholangiocarcinoma (N = 1), negative/atypical (N = 31), and inadequate (N = 1). Stones were found in 23/41 (56%) patients, of which 7/23 (30%) were missed on cholangiography and detected only by cholangioscopy. 9/23 (39%) underwent cholangioscopy-directed lithotripsy. Stone clearance: complete (N = 10, 7 by cholangioscopy-directed lithotripsy after failed conventional stone extraction); partial (N = 7); and not attempted (N = 6). Median follow-up was 17.0 months (range 1-56). Clinical improvement was achieved in 25/40 (63%). Eight patients have undergone transplant and cholangiocarcinoma was present in the explant of two at 1 and 12 months post-cholangioscopy, respectively., Conclusions: This is the first series of patients with primary sclerosing cholangitis undergoing cholangioscopy for the evaluation of dominant strictures and cholangioscopy-directed stone therapy with demonstrable clinical benefits. Stones detected by cholangioscopy were missed by cholangiography in nearly one of three patients. Cholangioscopy-directed lithotripsy may be superior to conventional ERCP for achieving complete stone clearance. Despite the use of cholangioscopy, diagnosis of cholangiocarcinoma remains technically challenging.

Background & Aims: We report the usefulness of cholangioscopy in patients with indeterminate pancreaticobiliary pathology., Methods: A prospective collection of 62 consecutive patients during a period of 2.5 years who were referred to our tertiary referral center for cholangioscopy for indeterminate strictures suspicious for malignancy were included. Tissue sampling followed cholangioscopic visualization. Biopsies were obtained under direct visualization (cholangioscopy-directed) or through the duodenoscope (cholangioscopy-assisted)., Results: Sixty-two patients had 72 examinations. Forty patients had nondiagnostic sampling before cholangioscopy. Indications were stricture (n = 67: 16 primary sclerosing cholangitis, 51 non-primary sclerosing cholangitis), ductal dilation, or intraductal mass (n = 5). Biopsies were not performed in 19 because cholangioscopy did not identify suspicious lesions. Of the remaining 53 procedures, 29 underwent either cholangioscopy-directed or cholangioscopy-assisted biopsy, and 24 had both. Cholangioscopy findings consisted of primary sclerosing cholangitis only (n = 18), benign stricture or inflammatory changes (n = 18), bile duct cancer (n = 14), normal (n = 10), pancreatic cancer (n = 5), and other (n = 7). Fifty-eight patients (94%) had follow-up for a mean of 12.4 months (95% confidence interval, 10.1-14.7). Sixteen of 18 (89%) patients with a final diagnosis of malignancy were detected with cholangioscopy. The 2 missed cancers were intrahepatic cholangiocarcinomas. Overall, sensitivity to detect malignancy by cholangioscopy with and without biopsy was 89%, specificity 96%, positive predictive value 89%, and negative predictive value 96%., Conclusions: Cholangioscopy with and without biopsy is highly accurate in diagnosing and excluding pancreaticobiliary malignancy in patients with indeterminate strictures.

Endoscopic ultrasound-guided fine-needle aspiration is emerging as the preferred technique for the cytologic diagnosis of various gastrointestinal lesions. This technique may not be routinely available, but there is still a role for endoscopic or endoscopic ultrasound-assisted fine-needle aspiration. This article provides an overview of the evolution of these various techniques and discusses the advantages, disadvantages, indications, and contraindications of each.

Objective: To compare the serum-ascites albumin gradient to the exudate-transudate concept in the classification of ascites., Design: Prospective collection of ascitic fluid data from patients with well-characterized causes of ascites., Setting: Hepatology inpatient and outpatient ward and consult service of a large, urban hospital., Patients: A total of 901 paired serum and ascitic fluid samples were collected from consecutive patients with all forms of ascites., Interventions: None., Main Outcome Measures: The utility of the serum-ascites albumin gradient and the old exudate-transudate concept (as defined by ascitic fluid total protein concentration [AFTP]) were compared for their ability in discriminating the cause for ascites formation., Results: The albumin gradient correctly differentiated causes of ascites due to portal hypertension from those that were not due to portal hypertension 96.7% of the time. The AFTP, when used as defined in the old exudate-transudate concept, classified the causes of ascites correctly only 55.6% of the time. This resulted in part because the AFTP of most spontaneously infected samples (traditionally expected to be exudates) was low, and the AFTP of most cardiac ascites samples (traditionally expected to be transudates) was high., Conclusions: The exudate-transudate concept should be discarded in the classification of ascites. The serum-ascites albumin gradient is far more useful than the AFTP as a marker for portal hypertension, but the latter remains a useful adjunct in the differential diagnosis of ascites.

Patients with low protein ascites and deficient ascitic fluid opsonic activity have been shown to be unusually predisposed to development of spontaneous bacterial peritonitis. Survivors of spontaneous peritonitis frequently develop recurrent infection. Diuresis has been shown to increase the ascitic fluid opsonic activity of patients who have never had spontaneous bacterial peritonitis. Patients with adequate opsonic activity are protected from ascitic fluid infection. Theoretically, the subset of patients who develop spontaneous peritonitis may have such severe liver disease that (i) their ascites is refractory to diuretic therapy or (ii) their ascitic fluid opsonic activity does not increase in response to diuresis. In this study, opsonic activity and concentrations of total protein and complement components were measured in the ascitic fluid of 11 patients who were hospitalized with spontaneous bacterial peritonitis and who responded to oral diuretics. The mean values of all of these parameters were found to increase significantly comparing the end-of-diuresis samples to the specimens that were diagnostic of ascitic fluid infection. Patients who survive spontaneous bacterial peritonitis are able to increase their ascitic fluid total protein and opsonic activity in response to diuresis. This increase in endogenous antimicrobial activity may help prevent recurrence of ascitic fluid infection.

In an attempt to determine the optimal duration of therapy of spontaneous bacterial peritonitis, 100 patients with neutrocytic ascites and suspected spontaneous bacterial peritonitis were randomized to short-course vs. long-course treatment groups. Empiric therapy was initiated before the results of ascitic fluid culture were available. Of the 90 patients who met strict criteria for spontaneous bacterial peritonitis or culture-negative neutrocytic ascites, 43 were randomized to a group receiving 5 days and 47 to a group receiving 10 days of single-agent cefotaxime, 2 g IV every 8 hours. Infection-related mortality (0% vs. 4.3%), hospitalization mortality (32.6% vs. 42.5%), bacteriologic cure (93.1% vs. 91.2%), and recurrence of ascitic fluid infection (11.6% vs. 12.8%) were not significantly different between the 5- and 10-day treatment groups, respectively. Recurrence rates were comparable to the values reported in the literature. The cost of antibiotic and antibiotic administration were significantly lower in the short-course group. Short-course treatment of spontaneous bacterial peritonitis is as efficacious as long-course therapy and significantly less expensive.

Ascitic fluid pH and lactate concentration have been proposed as useful tests for the detection of ascitic fluid infection. However, past studies involved small numbers of infected patients, and all did not use optimal culture techniques. This large study was performed using highly sensitive culture methods and sought (a) to compare the sensitivity, specificity and accuracy of pH and lactate to that of the ascitic fluid neutrophil count and (b) to determine whether evaluation of ascitic fluid pH or lactate (or arterial-ascitic fluid pH or lactate gradient) would result in improved decision-making regarding empirical treatment of suspected ascitic fluid infection. Analysis of 206 ascitic fluid specimens obtained in 175 patients, including 101 infected specimens, revealed that ascitic fluid (or arterial-ascitic fluid) pH and lactate were less than 50% sensitive in detecting bacterial peritonitis and that these tests did not improve clinical decision-making about empirical treatment of suspected ascitic fluid infection. Although statistically significant differences in ascitic fluid pH were detected between infected samples and control samples, these differences did not appear to be clinically helpful. The ascitic fluid pH was 0% sensitive in detecting the presence of bacteria in the absence of neutrophils (i.e., no such specimens had a pH lower than 7.35). Ascitic fluid pH correlated well with neutrophil count and appears to be, at least in part, an indirect measure of the presence of neutrophils in ascitic fluid. Measurement of pH or lactate (or arterial-ascitic fluid gradients) is not helpful in the clinical management of infected ascitic fluid.

Patients with high peripheral leukocyte counts are sometimes found to have high leukocyte counts in ascitic fluid in the presence of negative cultures. To determine if peripheral leukocytosis (greater than or equal to 20 x 10(9)/L) by itself can result in high leukocyte or neutrophil counts in ascites, 29 patients were studied. A total of 31 paracenteses were performed in these patients as soon as the high peripheral leukocyte count was determined. Culture of ascitic fluid was performed using blood-culture bottles. The mean peripheral leukocyte count was 29.3 +/- 9.3 x 10(9)/L, with a mean neutrophil count of 19.9 +/- 6.5 x 10(9)/L. The mean ascitic fluid neutrophil count was 0.064 +/- 0.054 x 10(9)/L (range, 0.007 to 0.197 x 10(9)/L). No significant correlation was found between peripheral neutrophil (or leukocyte) count and neutrophil (or leukocyte) count in ascitic fluid. Marked peripheral leukocytosis (or neutrophilia) does not seem to have an effect on the leukocyte or neutrophil count in ascitic fluid.

Ascitic fluids from patients suspected of having spontaneous bacterial peritonitis were inoculated into blood culture bottles (i) at the bedside and (ii) in the laboratory after a delay. In 29 episodes in which the bedside bottles were culture positive, only 22 (75.9%) of the laboratory-inoculated sets demonstrated growth; this difference was statistically significant (P less than 0.02).

Therapeutic paracentesis has recently been reported to eliminate ascites in patients with cirrhosis more rapidly than diuresis. However, diuresis has been shown to increase ascitic fluid opsonic activity. Patients with adequate ascitic fluid opsonic activity have been reported to be protected from spontaneous bacterial peritonitis. In this randomized controlled trial, 19 patients with cirrhotic ascites were treated with diuresis versus daily therapeutic paracenteses during 20 hospitalizations. Serum and ascitic fluid complement concentrations and ascitic fluid opsonic activity were measured at the beginning and end of treatment. Although opsonic activity increased significantly (p less than 0.01) in patients treated with diuresis, this parameter was stable in the paracentesis group. The stability of the ascitic fluid opsonic activity and complement concentration in the paracentesis group were maintained at the expense of a decrease in serum complement, whereas serum and ascitic fluid complement increased in the diuresis group. Diuresis may have the advantage over therapeutic paracentesis of providing better protection from spontaneous bacterial peritonitis. Study of larger numbers of patients will determine if these changes in complement concentrations and opsonic activity translate into an increased risk of spontaneous bacterial peritonitis in vivo.