Introduction: Colonoscopes ca potentially become incarcerated in inguinal hernia sacs during routine colonoscopies. The entrapment of colonoscopes may occur when patients present with unknown inguinal hernias. Entrapment can occur during the insertion or withdrawal of the scope. We report a case of a screening colonoscopy resulting in entrapment of a colonoscope in a left inguinal hernia, which was managed by applying pressure to the hernia site. Case Description/Methods: AH is a 66-year-old, white male who presented to the ambulatory surgical center for a screening colonoscopy. During the procedure, the scope repeatedly ended up in the blind end. It was evident the patient had a left inguinal hernia, and the scope was entering the hernia sac (Figure). Subsequently, the endoscopist withdrew the scope to prevent scope entrapment in the hernia sac, while the assistant put pressure on the hernia site under the patient’s gown to reduce the hernia sac. The colonoscopy was reattempted, while the assistant continued to push on the hernia site, and the procedure was completed without further difficulties. Discussion: There have been 2 previous case reports of scope entrapment in a patient’s hernia sac resulting in the scope being removed using either surgery, fluoroscopy, or the pulley method.1, 2 It is best to avoid performing a colonoscopy for patients with an irreducible hernia. For a reducible hernia, applying pressure on the hernia site may ensure that the scope does not enter the hernia sac. If a patient has an unknown hernia in an open-access colonoscopy, then the endoscopist may not be prepared for a hernia until they start the procedure. Gastroenterologists should be aware of the consequences of patients presenting with unknown inguinal hernias, especially if they are irreducible, to avoid potential complications and emergent operations. Physicians performing colonoscopies should be cognizant of the potential risk to patients with large, irreducible inguinal hernias. Larger studies are needed to definitively mandate this recommendation.Figure 1.: CT of the abdomen revealing left inguinal hernia.

Gastrointestinal infections are common and gastroenterologists typically participate in the patients' care, especially when the disease is severe. Endoscopy is commonly performed as part of the evaluation and management of the disease. A variety of disorders may predispose the patient to infection, and in the immunosuppressed patient the cause and outcome are dictated by the severity of immunosuppression.

Aim: Microbiota can affect cancer susceptibility and progression by diverse mechanisms, such as modulating inflammation, inducing DNA damage, and producing metabolites involved in oncogenesis or tumor suppression.But there has been few reports of gut microbiome change regarding to gastric cancer stage.Therefore, we conducted the metagenomic study to investigate the gut microbial omposition of human gut with the healthy and cancer.Moreover, we compared the intestinal microbiota change in cancer stage using 16S rRNA transcript amplicon sequencing and bacteria culture method.Methods: Stool samples were collected from 27 gastric cancer patients.16S rRNA genes from stool sample were sequenced on the Illumina Miseq platform and further analyzed to evaluate the gut bacterial community.And bacteria strains were isolated from fecal sample.The microbes were sub-cultivated for 3-7 days on the LB, BHI, GAM and PYG agar plate medium in aerobic and anaerobic condition.Then, further identified by using the 16s rRNA gene sequencing.Result: The metagenomics analysis revealed the intestinal microbiota composition in healthy group and cancer group was different.The relative abundance of the family Ruminococcus and the genus Streptococcus in cancer group was higher than in those of the healthy group.While genus Prevotella was diminished in the cancer group.In the cancer group, the phylum Firmicutes and Bacteroidetes which are involved in the carcinogenic process were basically dominant in all of the stages.However, the relative abundance of the phylum Firmicutes and Bacteroidetes was decreased in stage IV than the other stages.Among them, the relative abundance of class Ruminococcaceae and genus Bacteroides were reduced remarkably.On the contrary the phylum Proteobacteria and Actinobacteria were increased at stage IV.Especially, the family Enterobacteriaceae was observed highly in stage IV.In the bacterial culture-based approach, 40 genera including Enterococcus, Clostridium, Bacillus, Lactobacillus, Bifidobacteria, Eubacteria, Anaerostipes were isolated in stage I.However, only 14 genera such as Streptococcus, Shigella, Clostridium, Escherichia, Enterococcus, Bifidobacterium, and Bacteroides were isolated at the other stages.Conclusion: The microbial community in gastric cancer stage IV is characterized by the increase in the relative abundance of family Enterobacteriaceae of the phylum Proteobacteria, as well as the decrease in the relative abundance of Bacteroides and Firmicute than those of stage I, II, III.In the cultivated method, the diversity of isolated bacteria was substantially reduced in gastric cancer stage II, III, IV than the stage I. Su1988

OBJECTIVES:Chronic pancreatitis is a significant medical problem that impacts a large number of patients worldwide. In 2014, we developed a disease-specific instrument for the evaluation of quality of life in this group of patients: pancreatitis quality of life instrument (PANQOLI). The goal of this study was to evaluate its psychometric properties: its reliability and its construct validity.METHODS:This is a cross-sectional multi-center study that involved 12 pancreatic disease centers. Patients who met the inclusion/exclusion criteria for chronic pancreatitis were invited to participate. Those who accepted were asked to complete seven questionnaires/instruments. Only patients who completed the PANQOLI were included in the study. Its reliability and its construct validity were tested.RESULTS:A total of 159 patients completed the PANQOLI and were included in the study. They had a mean age of 49.03, 49% were male, and 84% were Caucasian. Six of the 24 items on the scale were removed because of lack of inter-item correlation, redundancy, or lack of correlation to quality of life issues. The final 18-item scale had excellent reliability (Cronbach's alpha coefficient: 0.914) and excellent construct validity with good correlation to generic quality of life instruments (SF-12 and EORTC QLQ-C30/QLQ-PAN26) and lack of correlation to non-quality of life instruments (MAST and DAST). Through exploratory factor analysis, the PANQOLI was found to consist of four subscales: emotional function scale, role function scale, physical function scale, and "self-worth" scale.CONCLUSIONS:PANQOLI is the first disease-specific instrument to be developed and validated for the evaluation of quality of life in chronic pancreatitis patients. It has a unique subscale for "self-worth" that differentiates it from other generic instruments. Studies are currently under way to evaluate its use in other populations not included in this study.

Context Pancreatic panniculitis is a very rare complication associated with pancreatic disease and perhaps even a presage to pancreatic pathology. Case report We present a case of pancreatic panniculitis in a 61 year old patient who was treated for sudden onset of abdominal pain associated with nausea and vomiting secondary to acute pancreatitis of unknown etiology. He subsequently developed skin lesions consistent with pancreatic panniculitis which gradually improved after resolution of his acute condition and treatment with topical steroid cream. Conclusion We discuss and review the literature along with highlighting for the readers the important clinical and histopathologic features of acute pancreatitis associated pancreatic panniculitis.

IMPORTANCE Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy. OBJECTIVE To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predictive of pain relief. DESIGN, SETTING, AND PATIENTS Multicenter, sham-controlled, randomized trial involving 214 patients with pain after cholecystectomy without significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis randomly assigned (August 6, 2008-March 23, 2012) to undergo sphincterotomy or sham therapy at 7 referral medical centers. One-year follow-up was blinded. The final follow-up visit was March 21, 2013. INTERVENTIONS After ERCP, patients were randomized 2:1 to sphincterotomy (n = 141) or sham (n = 73) irrespective of manometry findings. Those randomized to sphincterotomy with elevated pancreatic sphincter pressures were randomized again (1:1) to biliary or to both biliary and pancreatic sphincterotomies. Seventy-two were entered into an observational study with conventional ERCP managemeny. MAIN OUTCOMES AND MEASURES Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention. RESULTS Twenty-seven patients (37%; 95% CI, 25.9%-48.1%) in the sham treatment group vs 32 (23%; 95% CI, 15.8%-29.6%) in the sphincterotomy group experienced successful treatment (adjusted risk difference, -15.6%; 95% CI, -28.0% to -3.3%; P = .01). Of the patients with pancreatic sphincter hypertension, 14 (30%; 95% CI, 16.7%-42.9%) who underwent dual sphincterotomy and 10 (20%; 95% CI, 8.7%-30.5%) who underwent biliary sphincterotomy alone experienced successful treatment. Thirty-seven treated patients (26%; 95% CI,19%-34%) and 25 patients (34%; 95% CI, 23%-45%) in the sham group underwent repeat ERCP interventions (P = .22). Manometry results were not associated with the outcome. No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 15 patients (11%) after primary sphincterotomies and in 11 patients (15%) in the sham group. Of the nonrandomized patients in the observational study group, 5 (24%; 95% CI, 6%-42%) who underwent biliary sphincterotomy, 12 (31%; 95% CI, 16%-45%) who underwent dual sphincterotomy, and 2 (17%; 95% CI, 0%-38%) who did not undergo sphincterotomy had successful treatment. CONCLUSIONS AND RELEVANCE In patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy vs sham did not reduce disability due to pain. These findings do not support ERCP and sphincterotomy for these patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00688662.

OBJECTIVES:Patients with several painful functional gastrointestinal disorders (FGIDs) are reported to have a high prevalence of psychosocial disturbance. These aspects have not been studied extensively in patients with suspected Sphincter of Oddi dysfunction (SOD).METHODS:A total of 214 patients with post-cholecystectomy pain and suspected SOD were enrolled in seven US centers in a multicenter-randomized trial (Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction). Baseline assessments included pain descriptors and burden, structured psychosocial assessments of anxiety/depression, coping, trauma, and health-related quality of life. Patients with high levels of depression, suicidal ideation, or psychosis were excluded.RESULTS:The study population (92% female, mean age 38) reported anxiety (9%), depression (8%), past sexual trauma (18%), and physical abuse (10%). Of the total screened population (n=1460), 3.9% of the patients were excluded because of the presence of defined severe psychological problems. The mean medical outcomes study short-form-36 (SF-36) physical and mental composite scores were 38.70 (s.d.=7.89) and 48.74 (s.d.=9.60), respectively. Most subjects reported symptoms of other FGIDs. There were no correlations between the extent of the pain burden in the 3 months before enrollment and the baseline anxiety scores or victimization history. However, those with greater pain burden were significantly more depressed. There were no meaningful differences in the psychosocial parameters in subjects with or without irritable bowel, and those who had cholecystectomy for stones or functional gallbladder disease. Those declining randomization were comparable to those randomized.CONCLUSIONS:Psychosocial comorbidity in SOD is high. However, it does not appear to differ significantly from that reported in surveys of age- and gender-matched general populations, and may be lower than reported with other FGIDs.

A 62-year-old man presented with melena for 3 weeks. He had undergone a pylorus-preserving Whipple’s operation 2 years back for a diagnosis of cholangiocarcinoma, completed chemotherapy and a recent computed tomography (CT) scan was normal. Physical examination showed pallor. Investigations showed hemoglobin (7.8 g/dL) requiring 3 units of packed red blood cells (PRC) and negative esophagogastroduodenoscopy (EGD)/colonoscopy. Considering an obscure bleeding source, we carried out an anterograde double balloon enteroscopy (DBE) under fluoroscopy (DBEEN-450T5, working channel 2.8 mm, 13.5-mm overtube; Fujinon, Saitama, Japan). Using a push and pull technique, the efferent limb of the Roux-en-Y anastomosis was identified. Further, the afferent limb was intubated where the hepaticojejunostomy was seen congested with arteriovenous malformations (AVM) along with an erosion, pulsating visible vessel and ooze (Fig. 1). The AVM were ablated with argon plasma coagulation (APC), 30 W, pulsed at 2 s (Erbe, Tübingen, Germany) and the vessel was clipped with two resolution clips (Boston Scientific, Natick, MA, USA) (Fig. 2). The bleeding resolved at patient discharge. Bleeding events from a hepaticojejunostomy are rare and could present either as occult or overt obscure gastrointestinal bleeding (OBGIB). Potential sources include ectopic varices, pseudoaneurysms, ulcers and AVM. The altered anatomy poses a challenge in identifying them. Pillcam is indefinite for visualization. As mentioned, DBE is beneficial, highlighting a few practice points: (i) carry out deep enteroscopy and negotiate difficult anatomical alterations of the small bowel; (ii) visualize source with advantage of wash and clean simultaneously; and (iii) offer immediate therapeutic hemostatic intervention. The present case is unique where a ‘dual’ approach (APC ablation and clipping) at the hepaticojejunostomy for hemostasis was carried out using DBE. The technical challenge was to maintain an optimal position with minimal looping such that advancement with the ablation catheter and deployment of an 11-mm wide jaw hemostatic clip was feasible. In conclusion, DBE offers an ideal approach to management of OBGIB in altered small bowel anatomy obviating the need for surgical or radiological intervention. Figure 1 Identification of hepaticojejunostomy with arteriovenous malformations at the anastomosis.

A 66-year-old man who had been found to have histologically-proven carcinoid located in the duodenal bulb distal to the pylorus ([Fig. 1 a]) was referred to our center for endoscopic resection. Endoscopic ultrasound (EUS) showed a 9-mm lesion extending into the submucosa but without invasion into the muscular layer. Endoscopic resection using both snare and ligation techniques failed ([Fig. 1 b]), so it was decided to remove the lesion using the over-the-scope clip (OTSC) system (Ovesco, Tübingen, Germany) [1]. The lesion was entrapped and suctioned into the channel and the OTSC was released ([Fig. 1 c]); however, resection of the lesion located above the clip failed. Therefore, we decided to leave the clip in situ and to repeat the endoscopy 2 weeks later.

Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time's deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, propofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been prohibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists worldwide.

Advances in endoscopic ampullectomy continue to mitigate concerns regarding incomplete removal of ampullary neoplasias, postprocedure complications, and insufficient treatment of tumors with undetected malignant foci or intraductal invasion. Advanced T staging of these lesions with endoscopic ultrasound and intraductal ultrasound, while useful tools for selection of candidates for snare polypectomy, should be limited to lesions either greater than 3 cm, bearing the macroscopic appearance of malignancy or unamenable to endoscopic therapy. Intraductal ultrasound has demonstrated T-staging accuracy superior to endoscopic ultrasound. One prospective study of prophylactic pancreatic stent placement and a number of retrospective studies have reported reduced complication rates. Recent studies continue to propose follow-up endoscopic retrograde cholangiopancreatography at 3-month intervals after ampullectomy to evaluate for recurrence and ablate residual tissue, with the interval increased to 6 to 12 months for 5 years on obtaining negative biopsies for adenomatous tissue. The development of thermal ablation, notably argon plasma coagulation, for fulguration of residual unresectable tumor, biductal sphincterotomy and prophylactic pancreatic pancreatic stent placement, and advanced diagnostic imaging mitigate the concerns leveled against endoscopic ampullectomy. In experienced hands, endoscopic papillectomy of noninvasive, benign ampullary lesions is a safe, technically feasible, and effective alternative to surgical resection. This study will focus on diagnosis and staging of ampullary adenomas and reviews indications for, and outcomes and complications of, endoscopic papillectomy.

Secretin-stimulated MRI (S-MRCP) is a non-invasive, radiation-free assessment of the pancreaticobiliary system. This is the first large randomized, blinded, multicenter study of the efficacy of RG1068-stimulated MRCP in identifying pancreatic duct abnormalities using contemporaneous ERCP was the diagnostic standard.

The role of pancreas divisum in unexplained acute pancreatitis is controversial. Most data on minor papilla therapy come from case series, most without controls, except 1 small randomized trial of 1-year stenting; most feel the latter is no longer acceptable therapy due to duct damage that occurs with longterm stenting. The FRAMES (Frequency of Recurrent Acute pancreatitis after Minor papilla Endoscopic Sphincterotomy) study is an NIH study in its pilot phase, aiming to examine prospective outcomes and trial feasibility in this group of patients.

considered infected if cultures were positive (gold standard).Continuous values were expressed in median and range and comparisons were performed using non-parametric tests.Results: Between January 2010 and November 2011, 26 patients (17 males, 65%) were included.Median age was 50 years.The underlying disease was acute (AP) (n=15, 58%) or chronic pancreatitis (n=11, 42%).Median time between onset of symptoms and drainage was 56 days (14-300) for AP patients.Antibiotics had been previously administered in 9 patients (35%).Indications for drainage included pain (n=13, 50%) and clinical suspicion of infection (n=9, 35%).The median delay between DW-MRI and EUS drainage was 0 days (0-14).Based on DW-MRI, median PFC size was 86mm (25-960) and the content was considered to contain high protein fluid (blood or pus) in 13 cases (50%).Restriction in diffusion in the PFC suggested infection in 6 patients (23%).Based on EUS, most of PFCs were hypoechogenic (n=22, 84.6%) and contained debris in 19 cases (73%).Aspirated fluid was described as pus in 7 cases (27%).Median CEA, protein and lipase levels were, respectively, 9ng/ml (0.3-350), 2.7 gr/dl (0.4-4.1) and 31915 IU/L (25-717270).Bacteriological cultures were positive in 9 patients (35%).Sensitivity, specificity, accuracy, negative and positive predictive values of DW-MRI for predicting PFC infection were respectively 55.5% (5/9), 94% (16/17), 80% (21/26), 80% (16/20) and 83% (5/6).These values increased if we considered only patients without previous antibiotics (n=17) (respectively 75%, 92%, 88%, 92% and 75%).Median ADC was significant lower in infected PFCs (2.8 vs 1.1, p= 0.045).Conclusions: DW-MRI is a promising diagnostic tool concerning PFC assessment before drainage.Preliminary results disclose high specificity and negative predictive values, which can help in excluding PFC infection and determining time of drainage.

Purpose: The purpose of this presentation is to describe the psychometric properties of the Pancreatitis Quality of Life Instrument (PANQOLI) scale. Methods: This study used a cross-sectional survey design where patients with chronic pancreatitis were identified and screened from 11 pancreatic disease clinics throughout the U.S. Patients with confirmed chronic pancreatitis were provided with: a) 24-item version of the PANQOLI, b) other QOL instruments (Short-Form 12, European Organization Research Treatment Consortium-Pancreatic cancer instrument), and c) non-QOL instruments (Drug Abuse Screening Test [DAST], Michigan Alcohol Screening Test [MAST], and Marlowe-Crowne). Statistical analysis of the PANQOLI was performed to evaluate its reliability and construct validity. Results: A total of 175 patients were recruited. Sixteen subjects had missing data on the PANQOLI and were excluded from the study. The remaining 159 participants comprise the sample. Demographics did not reveal any significant differences between those included and those who were excluded from the study in terms of age, gender, race, smoking history, or severity of the disease. The original 24-item scale was reduced to 18 items due to item redundancy identified during the instrument analysis. Using Principal Component Analysis (PCA), this final 18-item scale captured 4 areas that impact quality of life in chronic pancreatitis patients: 1) physical function, 2) social function, 3) emotional function, and 4) self-esteem (Table 1). The mean score for this final 18-item scale in patients with chronic pancreatitis was 66.6 (SE 1.554, SD 19.6) with a normal distribution. The PANQOLI demonstrated excellent reliability (Cronbach's alpha=.924). It also correlated very well with other QOL instruments but not with non-QOL instruments indicating excellent construct validity (Table 2). Univariate analysis did not reveal any significant bias in the results of the scale based on study site, race, sex, smoking, or diabetes, indicating that it can be widely used in this population of patients. However, as expected with quality of life instruments, there was a significant difference based on age and on pain requiring narcotic medications.Table 1: Pancreatitis quality of life instrument (PANQOLI)Table 2: PANQOLI correlation to other instrumentsConclusion: PANQOLI is the first disease-specific instrument developed to measure the quality of life in chronic pancreatitis patients. In a multi-center evaluation of the scale, this 18-item instrument demonstrated excellent reliability and construct validity. Self esteem is a unique feature of this instrument which may increase its specificity and sensitivity in this group of patients. This hypothesis will need to be tested in future studies.

BackgroundAlthough endoscopy is being increasingly used for PFC drainage, data on clinical outcomes is limited due to the small numbers of patients, varied procedural techniques and multiple operators.AimEvaluate the clinical outcomes of endoscopic transmural drainage of PFCs in a large cohort of patients performed using a uniform technique.MethodsThe endoscopic database was queried for all patients who underwent drainage of PFCs using a standardized technique at a tertiary care center over a 6 year period. Prior to transmural drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct (PD) leak. PFCs were drained by conventional transmural drainage (CTD) or under EUS-guidance based on the presence or absence of luminal compression (LC) and patient-related risk factors. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Treatment success was defined as successful resolution of PFC by CT and symptoms at 8-week follow-up. Long-term follow-up and data on complications were collected prospectively.ResultsA total of 200 patients (mean age 51.7yrs, [SD=15.09], male 122) underwent PFC drainage that was classified as acute or chronic pseudocyst in 103 (51.5%), abscess in 43 (21.5%) and walled-off pancreatic necrosis (WOPN) in 54 (27%). Etiology of PFC was alcohol in 68, idiopathic in 42, gallstones in 38, post-surgical in 33 and other causes in 19. PFC s were drained by CTD in 56 (28%) and by EUS in 144 (72%) patients; LC was evident at endoscopy in 81 patients (40.5%). Mean PFC diameter was 100.6mm (SD=39.2). Sixty nine patients (34.5%) had successful PD stent placement. Median duration of follow-up was 196 days. Overall, treatment success was 85% that did not vary between CTD and EUS (83.9% vs. 85.4%, p=0.79). The treatment success rate was higher for pseudocyst and abscess compared to WOPN (93.2% vs. 62.9%, p<0.0001). Complications were encountered in 10 patients ( 5%, 95% CI [2.7%, 8.9]) that included perforation in 2, bleeding 3, infection 3, stent migration 1 and death in 1 patient. Three other patients died of multi-organ dysfunction unrelated to the procedure. Treatment success was more likely for patients with pancreatic pseudocyst and abscess than WOPN (Adj. OR =7.3, 95% CI[2.9, 18.2], p<0.0001) when adjusted for type of endoscopic modality used for drainage, accessory used for drainage (stent vs. stent and drainage catheters) and etiology, size and location of PFC.ConclusionsEndoscopic drainage is highly effective for the management of patients with PFCs, particularly non-necrotic collections. As less than 50% of patients with PFCs have a luminal compression, EUS is imperative in a majority of cases to facilitate safe transmural access. BackgroundAlthough endoscopy is being increasingly used for PFC drainage, data on clinical outcomes is limited due to the small numbers of patients, varied procedural techniques and multiple operators. Although endoscopy is being increasingly used for PFC drainage, data on clinical outcomes is limited due to the small numbers of patients, varied procedural techniques and multiple operators. AimEvaluate the clinical outcomes of endoscopic transmural drainage of PFCs in a large cohort of patients performed using a uniform technique. Evaluate the clinical outcomes of endoscopic transmural drainage of PFCs in a large cohort of patients performed using a uniform technique. MethodsThe endoscopic database was queried for all patients who underwent drainage of PFCs using a standardized technique at a tertiary care center over a 6 year period. Prior to transmural drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct (PD) leak. PFCs were drained by conventional transmural drainage (CTD) or under EUS-guidance based on the presence or absence of luminal compression (LC) and patient-related risk factors. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Treatment success was defined as successful resolution of PFC by CT and symptoms at 8-week follow-up. Long-term follow-up and data on complications were collected prospectively. The endoscopic database was queried for all patients who underwent drainage of PFCs using a standardized technique at a tertiary care center over a 6 year period. Prior to transmural drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct (PD) leak. PFCs were drained by conventional transmural drainage (CTD) or under EUS-guidance based on the presence or absence of luminal compression (LC) and patient-related risk factors. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Treatment success was defined as successful resolution of PFC by CT and symptoms at 8-week follow-up. Long-term follow-up and data on complications were collected prospectively. ResultsA total of 200 patients (mean age 51.7yrs, [SD=15.09], male 122) underwent PFC drainage that was classified as acute or chronic pseudocyst in 103 (51.5%), abscess in 43 (21.5%) and walled-off pancreatic necrosis (WOPN) in 54 (27%). Etiology of PFC was alcohol in 68, idiopathic in 42, gallstones in 38, post-surgical in 33 and other causes in 19. PFC s were drained by CTD in 56 (28%) and by EUS in 144 (72%) patients; LC was evident at endoscopy in 81 patients (40.5%). Mean PFC diameter was 100.6mm (SD=39.2). Sixty nine patients (34.5%) had successful PD stent placement. Median duration of follow-up was 196 days. Overall, treatment success was 85% that did not vary between CTD and EUS (83.9% vs. 85.4%, p=0.79). The treatment success rate was higher for pseudocyst and abscess compared to WOPN (93.2% vs. 62.9%, p<0.0001). Complications were encountered in 10 patients ( 5%, 95% CI [2.7%, 8.9]) that included perforation in 2, bleeding 3, infection 3, stent migration 1 and death in 1 patient. Three other patients died of multi-organ dysfunction unrelated to the procedure. Treatment success was more likely for patients with pancreatic pseudocyst and abscess than WOPN (Adj. OR =7.3, 95% CI[2.9, 18.2], p<0.0001) when adjusted for type of endoscopic modality used for drainage, accessory used for drainage (stent vs. stent and drainage catheters) and etiology, size and location of PFC. A total of 200 patients (mean age 51.7yrs, [SD=15.09], male 122) underwent PFC drainage that was classified as acute or chronic pseudocyst in 103 (51.5%), abscess in 43 (21.5%) and walled-off pancreatic necrosis (WOPN) in 54 (27%). Etiology of PFC was alcohol in 68, idiopathic in 42, gallstones in 38, post-surgical in 33 and other causes in 19. PFC s were drained by CTD in 56 (28%) and by EUS in 144 (72%) patients; LC was evident at endoscopy in 81 patients (40.5%). Mean PFC diameter was 100.6mm (SD=39.2). Sixty nine patients (34.5%) had successful PD stent placement. Median duration of follow-up was 196 days. Overall, treatment success was 85% that did not vary between CTD and EUS (83.9% vs. 85.4%, p=0.79). The treatment success rate was higher for pseudocyst and abscess compared to WOPN (93.2% vs. 62.9%, p<0.0001). Complications were encountered in 10 patients ( 5%, 95% CI [2.7%, 8.9]) that included perforation in 2, bleeding 3, infection 3, stent migration 1 and death in 1 patient. Three other patients died of multi-organ dysfunction unrelated to the procedure. Treatment success was more likely for patients with pancreatic pseudocyst and abscess than WOPN (Adj. OR =7.3, 95% CI[2.9, 18.2], p<0.0001) when adjusted for type of endoscopic modality used for drainage, accessory used for drainage (stent vs. stent and drainage catheters) and etiology, size and location of PFC. ConclusionsEndoscopic drainage is highly effective for the management of patients with PFCs, particularly non-necrotic collections. As less than 50% of patients with PFCs have a luminal compression, EUS is imperative in a majority of cases to facilitate safe transmural access. Endoscopic drainage is highly effective for the management of patients with PFCs, particularly non-necrotic collections. As less than 50% of patients with PFCs have a luminal compression, EUS is imperative in a majority of cases to facilitate safe transmural access.

There are no prior studies evaluating the impact of biliary stents on EUS-guided FNA. Compare the diagnostic yield of EUS-guided FNA in patients with or without biliary stents and presenting with obstructive jaundice secondary to solid pancreatic masses. Retrospective study of all patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-guided FNA over 5-yrs. Only patients in whom the pancreatic masses were sampled were included. Excluded were patients who underwent EUS-FNA of distant metastasis. The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic or metal biliary stents. The secondary objective was to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis between patients with or without stents and between plastic or metal stents. The gold standard was surgical cytopathology, death by disease progression or long-term follow-up. 216 patients with obstructive jaundice secondary to solid pancreatic mass lesions underwent EUS-guided FNA over a 5-yr period. Of 216 patients, 152 (70%) had biliary stents and 64 (30%) had no stents in place. Of 152 patients with biliary stents, 106 (70%) were plastic and 46 (30%) were metal. There was no difference in patient characteristics (Male, 49% vs. 50%, p=0.89; mean age 66.6 vs. 68.3 yrs, p=0.31) or size of the pancreatic mass on CT (2.9 vs. 3.0 cm; p=0.56) between patients with or without biliary stents, respectively. At EUS-guided FNA, the diagnosis was pancreatic cancer in 156 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%) and indeterminate in 12 (6%). There was no difference in rates of diagnostic accuracy for pancreatic cancer, chronic pancreatitis or other cancer between patients with or without stents (94.7% vs. 93.8 %; p= 0.75) and between patients with plastic or metal stents (94.3% vs. 95.6%; p=0.99), respectively. The rates at which indeterminate diagnosis were encountered was not significantly different between patients with or without stents (5.3% vs. 6.3%; p=0.75) and between plastic or metal stents (5.7% vs. 4.4%; p=0.99), respectively. The total number of false negative FNA's was 3 (1.4%) the rates of which was not significantly different between patients with or without biliary stents (1.97% vs. 0%; p=0.56) and between plastic or metal stents (1.9% vs. 2.2%; p=0.99), respectively. The median number of passes to establish diagnosis was not significantly different between patients with or without stents (2.5 vs. 2; p=0.051) and between plastic or metal stents (3 vs. 2; p=0.71), respectively. The presence or absence of a biliary stent, whether plastic or metal, does not impact the diagnostic yield or technical difficulty at EUS-guided FNA.

Although endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) is performed real-time under sonographic guidance, there are reports of complications in several studies. The frequency at which complications occur during EUS-guided drainage of PFCs is unclear. Objective: Assess the frequency at which complications are encountered during EUS-guided drainage of PFCs. This is a retrospective study of consecutive patients who underwent EUS-guided drainage of PFCs at two tertiary referral centers over an 8-yr period. Using a therapeutic linear echoendoscope, the PFC was identified and accessed using a 19ga FNA needle. A 0.035 inch guidewire was coiled in the PFC, the tract was dilated, and then 2 to 3 transmural stents were deployed. Additional nasocystic catheters were deployed in patients with necrotic fluid collections. Electrocautery was not used to access the PFC in any patient. Patients were followed prospectively for the development of complications. The main outcome measure was to assess the frequency of complications during EUS-guided drainage of PFCs. Treatment success was defined as resolution of clinical symptoms and PFC on follow-up imaging at 8-12 weeks. A total of 294 patients (Male=188 [63.9%]; Mean age 50.6yrs, [SD=16.01]) underwent EUS-guided drainage of PFCs that were classified as acute, chronic or infective pseudocyst in 244 and walled off pancreatic necrosis [WOPN] in 50. The mean diameter of the PFCs was 94.7mm (SD=36.7). The overall rate of treatment success was 88%. Complication of perforation occurred in 4 (PFC location: head/uncinate in 3 and body in 1) patients (frequency 1.3%, 95% CI [0.04%, 2.7%]), bleeding 7 (2.4%, 95% CI[0.64%, 4.12%]), infection 14 (4.7%, 95% CI [2.3%, 7.1%]) and stent migration in 3 (1.1%, 95% CI [0.1%, 2.2%]). There were six deaths from multi-organ dysfunction within 30 days of EUS of which none were procedure related. EUS-guided drainage of PFCs, in experienced hands, is associated with a low complication rate. This data can be used by endosonographers to counsel patients on the frequency of complications during EUS-guided drainage of PFCs.