Brush cytology is the initial intervention when evaluating biliary strictures. Biliary brush cytology is known for its low sensitivity (but high specificity) and may be accompanied by biopsies and/or fluorescent in situ hybridization (FISH) to improve diagnostic yield. This study aimed to identify features to enhance cytological sensitivity, and assess which sampling method(s) improve identification of pancreatobiliary adenocarcinomas (PBCa).

BACKGROUND AND STUDY AIMS:Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate.PATIENT AND METHODS:Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement.RESULTS:Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement.CONCLUSIONS:Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.

EUS-FNA is the diagnostic test of choice when evaluating pancreatic masses. In cases when imaging is suggestive of malignancy and the lesion appears surgically resectable it may be reasonable to proceed to definitive therapy without further sampling. Our goal in this study was to assess the benefits of preoperative EUS-FNA in such cases by evaluating the ability of EUS -FNA to (1) identify patients with a non-malignant disease and thus avoid potentially unnecessary surgery; (2) assess the accuracy of EUS to stage malignancy. We also examined the potential long term risk of a pre-operative EUS.

This is the case of a 47 year-old female with medical history of obesity, treated surgically with a sleeve gastrectomy. This was complicated by a gastric leak at the surgical site, forming an intraabdominal abcess. The abcess required surgical drainage and the gastric defect was treated with an over-the-scope clip and an esophageal stent placement. After discharge the patient developed abdominal pain and imaging revealed recurrence of the gastric leak. The patient was referred for repeat attempt at endoscopic closure of the leak. An endoscopic suturing device was adjusted over the therapeutic endoscope and the needle was loaded outside the patient. The scope was advanced through an over-tube. The esophageal and gastric lumen were defined and the lower border of the defect was identified. This tissue was puctured with the needle to thread the suture. Once secure, the scope was rotated in order to approach the opposite border of the defect. The needle was reloaded and a second “bite” was taken inorder to complete the stitch. Once both sides had been sutured, the defect borders were approximated by exerting significant tension on the sutures external to the endoscope. The suture was then cut and the end of the suture released with a tag attachement that secured it in place. Examination of the defect demonstrated closure. We then proceeded to place a covered metal esophageal stent, and this was sutured to the mucosa utilizing the suturing device. Stent migration is a common complication of intraluminal stents. Placing sutures is shown here to be a safe and effective strategy in the prevention of stent migration. Endoscopic suturing may also prove to be helpful in correcting transluminal defects.

Pancreatic neuroendocrine tumors (pNET) are among the rarest neoplasms, occurring in <1/100,000 people per year and represent 1-2% of all pancreatic tumors. Indications for resection are debated. We reviewed our tertiary center's large experience of nonfunctioning, asymptomatic pNETs and assessed the diagnostic yield of EUS-FNA with respect to mitotic rate, tumor size, Ki-67 index, lymph node involvement (LN+), lymphovascular invasion (LVI+) or any invasive features (peripancreatic fat, neural, perineural, lymphovascular, splenic or duodenal invasion) at the time of surgical resection.

The global burden of cancer continues to grow and is a major economic expenditure for all the developed countries, where cancer treatment represents 4.1 % – 9.3 % of total health care spending [1] [2] [3]. Along with universally growing health care costs, this is of particular concern in this period of financial crisis, with many countries facing a potential period of economic recession or stagnation. The increase in cost is not simply the result of an increase in the absolute number of cancer patients due to the aging of the population, but also to the introduction of very costly new antineoplastic agents and technologies [4]. Moreover, a substantial proportion of the costs for patients with solid tumors are related to surgery, which is perceived as the sole cure for patients with cancer [5]. Appropriate patient selection and accurate preoperative diagnosis and staging are therefore critical to avoiding unnecessary or ineffective surgery [4].

Accurate diagnosis of indeterminate biliary strictures remains a clinical challenge. The aim of this study was to assess the operating characteristics of fluorescence in situ hybridization (FISH) compared to cholangioscopic (Spyglass) targeted biopsies for the detection of malignancy in biliary tract strictures.

Accurate diagnosis of biliary strictures remains a challenge. Despite advanced and targeted methods of sample acquisition, improved cytologic criteria and even the addition of molecular markers such as chromosomal aneuploidy by FISH diagnosis of malignancy remains difficult. One of the reasons for this may be the pauci-cellular nature of biliary malignancies. Therefore, we hypothesized that cell free DNA from supernatant fluids associated with biliary brush specimens may overcome this limitation. Our goal was to evaluate the feasibility of isolating sufficient DNA for mutational analysis and to examine the potential benefit of adding this modality to brush cytology and FISH analysis.

EUS-FNA is the preferred method to sample pancreatic masses. Concerns have been raised that EUS-FNA may adversely affect outcomes in resectable pancreatic cancer, via mechanisms such as tumor seeding. The purpose of this study is to evaluate preoperative EUS-FNA as a risk factor for tumor recurrence and survival in patients with pancreatic adenocarcinoma.

Despite treatment advances pancreatic cancer remains one of the most lethal malignancies. It is expected that early detection and screening of high risk patient population may have the most significant impact on altering overall survival in this disease. Serologic biomarkers may be the most useful in early detection and histology-based markers may have the most significant role in differentiating benign, pre-malignant and malignant lesions. Here we review several serum and tissue-based biomarkers and summarize new data presented at the 2012 ASCO Gastrointestinal Cancers Symposium (Abstracts #151, #164, #188) on the potential role of PAM4 in pancreatic cancer screening and diagnosis.

TIF is a novel, endoluminal, incisionless surgery for GERD that provides near circumferential augmentation of the gastroesophageal flap valve via an esophago-gastric plication. MII-pH reflux monitoring is established as a method for detecting nonacid and acid reflux and can detect reflux in patients despite acid reduction therapy. MII-pH reflux monitoring data could offer objective proof of TIF efficacy as a treatment for GERD.

Introduction: MII-pH was performed on 8 patients who failed PPI therapy before and after Endolumenal “barrier” treatment and characterized for esophageal pH exposure, clearance time, total and supine reflux and proximal migrations (>15 cm). Methods: Eight GERD patients unresponsive to PPI therapy underwent 24 hour MII-pH testing. The MII-pH catheter was placed transnasally and manometrically located. All reflux events were measured by impedance and simultaneous pH-metry to characterize them into number and type (acid/nonacid) of events, as well as extent of proximal migration. Upright and supine positions could also be subcategorized. All eight patients underwent endoluminal therapy with Plicator (6) or Enteryx (2). Post-procedural MII-pH testing was performed. Results: Following endoluminal therapy, 5 patient were asymptomatic and not on PPI therapy. Two patients had symptomatic improvement, but remained on PPI therapy. Post-endoluminal therapy MII-pH measurements show improvements in Johnson-DeMeester scores, total pH exposure time, proximal migration height, and number of impedance reflux episodes, however bolus clearance time was not changed (see Table I for patient results). Conclusion: Patients with symptomatic GERD are dramatically helped by endoluminal therapy as evidenced by improvements in objective parameters as measured by MII-pH. Traditional pH only testing has been shown to miss the subgroups of patients with nonacid reflux as the cause of symptoms, especially patients tested on PPI therapy. Although subjective patient improvement was observed post Endoluminal therapy, addition of combined impedance and pH testing also showed improvements in objective paramenters of reflux. Treatment of properly selected symptomatic GERD patients with a “barrier” therapy such as endoluminal therapy appears effective. Tabled 1Pre and Post Endolumenal Therapy MII-pH Characteristics Patient Total pH Exposure (%) PRE/POST MeanBolus Clearance (sec) PRE/POST Johnson Demeester PRE/POST Reflux Episodes (total) PRE/POST Reflux Episodes (upright) PRE/POST Reflux Episodes (supine) PRE/POST Proximal Migration PRE/POST A ∗ NDO plicator 5.2 / 0.7 13 / 12 23.2 / 2.3 48 / 43 25 / 42 0 / 1 21 / 20 B Enteryx 9.0 / 4.5 8 / 13 37 / 19.5 49 / 39 42 / 29 7 / 10 12 / 19 C Enteryx 0.2 / 2.0 16 / 20 1.8 / 12 161 / 81 136 / 48 25 / 33 42 / 40 D ∗ NDO plicator 0.1 / 0 4 / 5 0.9 / 0.9 75 / 28 4 / 0 71 / 28 32 / 8 E ∗ NDO plicator 17 / 9.2 15 / 21 152 / 60.9 45 / 15 38 / 10 7 / 5 17 / 5 F ∗ NDO plicator 6.7 / 0.6 10 / 17 30 / 2.9 37 / 22 29 / 18 8 / 4 9 / 12 G ∗ NDO plicator 4.8 / 0.5 14 / 12 14.7 / 3.9 83 / 44 58 / 13 25 / 31 48 / 18 H ∗ NDO plicator 8.7 / 3.4 22 / 11 28 / 18 72 / 50 50 / 38 22 / 18 55 / 18 ∗ NDO plicator ∗∗ Enteryx Open table in a new tab

Introduction: MII-pH was used to detect nonacid reflux in patients who failed PPI therapy and might be helped by a “barrier” therapy such as endoluminal therapy. Methods: Six GERD patients unresponsive to PPI therapy underwent 24 hour MII-pH testing. The MII-pH catheter was placed transnasally and manometrically located. Symptom Index (SI) & Symptom Association Probability (SAP) were calculated to show symptoms associations with all reflux events as measured by impedance and characterized as acid or nonacid by pH-metry. SI is positive at ≧50% and SAP is positive at ≧95%. The proximal height of reflux migration was also measured. All six patients underwent endoluminal therapy with Plicator or Enteryx. Post-procedural MII-pH testing was performed. Results: Following endoluminal therapy, 5 patient were asymptomatic and not on PPI therapy. One patient had symptomatic improvement, but remained on PPI therapy. Mean and (median) values for pre-procedural symptom-reflux association include: SI + nonacid 21.69% (21.55%), SAP + nonacid 67.1% (80.2%), SI + acid 17.66% (22.97%), SAP + acid 59.2% (80.2%). Symptom association for nonacid reflux was more prevalent than that for acid reflux. Post-endoluminal therapy MII-pH measurements show improvements in symptom association analysis, proximal migration height of reflux, acid exposure, and impedance reflux episodes. (see Table I). Conclusion: Patients with symptomatic GERD who have more nonacid than acid exposure are dramatically helped by endoluminal therapy as evidenced by improvements in objective parameters as measured by MII-pH. In this group failing acid suppressive therapy, nonacid reflux was likely to be the major cause of their persistent symptoms. Traditional pH only testing would have missed this subgroup of patients. Impedance and pH testing improved the diagnostic yield of reflux monitoring and provides more accurate symptom association analysis. Furthermore, for those patients with normal or physiologic acid exposure, better symptom association analysis can be accomplished with combined pH and impedance reflux testing. Treatment of nonacid reflux with a “barrier” therapy such as endoluminal therapy appears effective in properly selected patients. Tabled 1MII-pH results: pre/post symptom association analysis Pre % mean Post % mean SI + acid 17.66 16.7 SI + nonacid 21.69 3.75 SAP + acid 59.2 29.0 SAP + nonacid 67.1 5.78 Proximal events 28.50 17.50 %