Introduction

The prediction of positive results of endoscopic ultrasonography guided tissue acquisition(EUS TA), including EUS fine needle aspiration(EUS FNA) and EUS fine needle biopsy(EUS FNB), has changed from rapid on-site evaluation(ROSE) to macroscopic on-site evaluation (MOSE). The average predictive positive rate is about eighties percent under MOSE. The intraoperative frozen section evaluation has been widely used by the surgeons. We conducted the study to evaluate if there is any benefit of intraoperative frozen section evaluation for increasing the predictive diagnostic yield of EUS FNB.

Aims & Methods

Aims: We compared the yield rate of EUS FNB for pancreatic solid lesions between MOSE and intraoperative frozen section evaluation and MOSE only.
Methods: The study was conducted at a single tertiary referral center from Aug. 2021 to Mar. 2023.
The patients who were indicated for EUS FNB were enrolled into the study.
During EUS FNB we sent the specimens from the first two passes for the frozen section after we considered adequate macroscopic visible tissue core. Later we would obtain other specimens from later passes for the permanent section (MOSE + Frozen group (MF group)). As for the control group we sent the specimens for the permanent section only (MOSE only group (M group)).
We compared the histological results of frozen and permanent sections and divided them into three subgroups as the frozen section being equal, inferior and superior to the permanent one.
The p-value <0.05 was defined as statistically significant.

Results

Total one hundred ninety four patients were enrolled into the study and ninety seven patients were divided into each group equally. Demographic characters were as the followings with MOSE with frozen group versus MOSE only one:
age 62+-14 vs 63+-12 years old
gender male to female 1.6: 1 vs 1.6 : 1
diagnosis of pancreatic solid lesion adenocarcinoma : neuroendocrine tumor : chronic pancreatitis 71:5:2 vs 41:5:12
average size of lesion 37.2+-16 vs 34.3+-13 mm
location of lesion uncinate process: head: neck: body: tail 4:32:5:20:11 vs 5:22:0:16:13
the most common location of lesion was head of pancreas on both groups
As for the results of EUS FNB, the pass for permanent section was 5.5 versus 5.8 (MF group vs M group, p=0.018 ) and the transgastric puncture route was 51 versus 53 patients and transduodenal route was 46 vs 44 patients (MF group vs M group). About the yield rate the MF group was 92.8% and the M group was 79.4% (p=0.006).
When comparing the histological results of frozen and permanent sections the frozen section was equal, inferior and superior to the permanent one as 63 (65%), 33 (34%) and 1 (1%) patient(s)(Table).
Table

Conclusion

When performing EUS FNB for pancreatic solid lesions, it seems to increase the predictive yield rate if we combine MOSE and intraoperative frozen section evaluation. There are some pitfalls about combined MOSE and intraoperative frozen section evaluation, such as prolonged procedure time and increased medical expenses due to frozen section evaluation.

References

1. Iwashita T, Yasuda I, Mukai T, et al. Macroscopic on-site quality evaluation of biopsy specimens to improve the diagnostic accuracy during EUS-guided FNA using a 19-gauge needle for solid lesions: a single-center prospective pilot study (MOSE study). Gastrointest Endosc 2015;81:177-85.

Introduction

Long-term outcomes of gastric subepithelial lesions have not been elucidated. To reveal the natural history, we initiated a prospective, 10-year follow-up of patients with small (≤20 mm) gastric subepithelial lesions in September 2014. Here, we report the results of an interim analysis of a prospective observational study.

Aims & Methods

In total, 567 patients with 609 lesions were prospectively registered between September 2014 and August 2016. The location, size, morphology, and number of subepithelial lesions were recorded on a web-based case report form.

Results

The endoscopic follow-up period was 4.60 ± 1.73 years (mean ± SD), and survival data were investigated for 5.28 ± 1.68 years. This interim analysis revealed that the estimated cumulative incidence of a size increase ≥5 mm, after accounting for patients’ death and resection of the tumor as competing risk events, was 4.5%. In addition, the estimated cumulative incidence of lesion size increase ≥5 mm or resection of lesions was 7.7% at 5 years, and that of size increase ≥10 mm or resection of lesions was 4.3% at 5 years.

Conclusion

These results indicate that approximately one in 13 patients with small (≤20 mm) gastric subepithelial lesions may require resection or further investigation for increased tumor size (≥5 mm) within five years under active surveillance.

References

Nishida T, Hirota S, Yanagisawa A et al. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008; 13: 416-30.

Disclosure

This study has been conducted as an Academic Committee Working Group of the Japan Gastroenterological Endoscopy Society.

Introduction

We have focused on the morphology of subepithelial tumors (SETs) and examined the possibility of noninvasive differentiation method based on differences in tumor morphology on endoscopic ultrasonography (EUS) still images. In a previous study, we found that leiomyoma has a lower circularity (4π×area/perimeter²; range = 0-1, 1 = a true circle) on EUS images than gastrointestinal stromal tumor (GIST) and schwannoma in lesions ≥2 cm, and that two-dimensional morphological evaluation was useful for the differentiation of gastrointestinal mesenchymal tumors (GIMTs) (Koizumi E, et al. Digestion 2022). In this study, we performed an interim analysis of the prospective study to assess the validity of this concept including lesions ≥1 cm, and further examined the feasibility of three-dimensional evaluation by measuring sphericity (a surface area of a sphere having the same volume as the object divided by a surface area of the object; range = 0-1, 1 = a true sphere) by using CT images.

Aims & Methods

For 54 cases of 1-5 cm gastric GIMTs with pathological diagnosis accumulated at two institutions from 2020 to the present, one representative EUS image, which showed a maximum cross-sectional surface of tumors, was selected. Two endoscopists who were blind to the histology of lesions independently measured the circularity three times per image by using an image analyzing software, and an average of six values in total was defined as individual circularity of each lesion for the analysis. Then, circularity of the leiomyoma group and the GIST + schwannoma group were compared, and the diagnostic performance at the optimal cutoff value was evaluated. Additionally, in four GIMT cases that had undergone thin-slice CT before the tissue sampling, we attempted to construct the lesion in three-dimensional image and measure the sphericity.

Results

The number of cases of leiomyoma/GIST/schwannoma were 8/42/4, respectively, and the mean tumor diameter was 14/22/25 mm, respectively. The circularity of the leiomyoma group was significantly lower than that of the GIST+ schwannoma group (0.83 vs. 0.90, p = 0.005), with a cutoff value of 0.92 and the highest diagnostic rate of 63% (area under the curve = 0.80, sensitivity 57%, specificity 100%). In addition, sphericity could be measured in all four cases in which three-dimensional evaluation was performed (one leiomyoma case and three GIST cases), and the mean value of calculated sphericity was 0.84.

Conclusion

The interim analysis suggested that two-dimensional morphological evaluation of SETs would be useful for differentiating leiomyoma even in small lesions by using the circularity assessment. It was also possible to construct a three-dimensional structure, which could more adequately represent the overall shape and expected more precise morphological evaluation by using the sphericity evaluation.

Introduction

To evaluate the utility of the unroofing technique in the diagnosis of gastrointestinal subepithelial tumors (SETs), we performed a multicenter retrospective study.

Aims & Methods

This study was conducted in 10 hospitals and involved all eligible patients who underwent unroofing techniques to gain biopsy for gastrointestinal SETs between April 2015 and March 2021. The primary endpoint was the rate of correct diagnosis with the unroofing technique, and the secondary endpoints were the incidence of adverse events and the factors contributing to the correct diagnosis.

Results

The study included 61 patients with 61 gastrointestinal SETs, a median tumor size of 20 mm, and a median procedure time of 38 minutes with 82% successful tumor exposure. The rate of tissue acquisition was 98.4%, and the rate of pathological diagnosis was 72.1%. In 44 cases with a pathological diagnosis, two showed discrepancies with the postresection pathological diagnosis. No factors, including facility experience, organ, tumor size, or tumor exposure, significantly affected the correct diagnosis. No significant differences in the correct diagnosis rate were observed between less than ten experiences and more than ten experiences (74.1 vs. 70.6%). The correct diagnosis rates for tumors <20 mm and ≥20 mm were 76.9% and 65.7%, respectively. There was one case of delayed bleeding and two cases of perforations.

Conclusion

The diagnostic yield of the unroofing technique was acceptable. The unroofing technique was beneficial regardless of institutional experience, organ, tumor size, or actual tumor exposure.

Introduction

There is no unanimity regarding the most appropriate needle to use for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). To date, new types of FNB needles have been designed, including the Fork-tip and Franseen needles. The Fork-tip is characterized by two sharp tips on opposite sides of the lumen, and the Franseen needles are characterized by three symmetric cutting tips. This study primarily aimed to compare the diagnostic utility and histological quality between the use of the Fork-tip and Franseen neesles in EUS-FNB for solid pancreatic lesions.

Aims & Methods

We retrospectively analyzed 187 patients at our center for solid pancreatic lesions, 75 of whom underwent EUS-FNB using a 22 G Franseen needle and 112 using a 22 G Fork-tip needle, from December 2019 to October 2022.

Results

After propensity-matched analysis, each group was adjusted to 66 cases. The results revealed that sex, age, route for puncture, and tumor size, site, and tumor type were not different between the Franseen and Fork-tip groups. Both groups were not significantly different in terms of number of punctures, procedure time, core tissue score, blood score, and technical success rate. From the histological findings, the most common final diagnosis was adenocarcinoma (107 patients), which was followed by a benign lesion (19 patients), and finally, the NET (6 patients). In this study, no adverse events during the procedure were encountered. The diagnostic accuracy of the Fork-tip group (92.4%; 61/66) was similar to that of the Franseen group (90.9%; 60/66) (P >0.99). The outcomes of the two groups were similar for the distinction between benign and malignant lesions. The rate of changes of operators from a trainee was significantly less in the Fork-tip group (9.1%, 6/66) than in the Franseen group (24.2%, 16/66) (P = 0.03). The reasons for operator changes were as follows: In the Franseen group, there were ten cases of difficulty in adjusting the puncture route from the second part of the duodenum, six cases of difficulty in penetrating the gastric wall from the stomach. In contrast, in the Fork-tip group, there were two cases of difficulty in adjusting the puncture route from the second part of the duodenum, two cases of difficulty in penetrating the gastric wall from the stomach, two cases of difficulty in avoiding vessels. All cases were successfully punctured after an expert took over.

Conclusion

Although in both groups, the diagnostic accuracy and other outcomes of procedures conducted, were not significantly different, the rate of changes of operator from a trainee to an expert was significantly less in the Fork-tip group than in the Franseen group. Thus, the Fork-tip needle was observed as good choice for trainees and the appropriate needle must be selected according to the situation.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB). In a recent Japanese multicenter retrospective cohort study, 63.6% of patients with ALGIB were ultimately diagnosed with CDB [1]. It has also been reported that CDB in ALGIB is reportedly more severe than in other entities [2, 3]. However, few reports have demonstrated the efficacy and safety of bowel preparation for patients undergoing urgent colonoscopy.

Aims & Methods

We aim to clarify choice a of bowel preparation for urgent colonoscopy in patients with colonic diverticular bleeding. In a multicenter retrospective cohort study at 10 institutions, we analyzed the endoscopic findings and clinical course of patients diagnosed with CDB who underwent urgent colonoscopy within 24 hours after admission. Bowel preparation consisted of oral consumption of 1 to 2 L of polyethylene glycol lavage (PEL); enemas were not used. We compared those CDB patients who underwent PEL (PEL group) with a control group who did not undergo PEL (non-PEL group) before and after propensity score matching. For the matching, we selected variables known at the time of hospital admission (i.e. age, sex, comorbidities, medications, performance status, and laboratory data). The primary endpoint of the study was length of hospital stay, and secondary endpoints included blood transfusion requirements, rebleeding rates, endoscopic findings, and complications.

Results

242 patients were enrolled in this study. The median age was 76 years, and 60.7% of patients were men (n = 147). Approximately half of the patients underwent bowel preparation with PEL prior to urgent colonoscopy (n = 129). We compared with clinical findings between the PEL and non-PEL groups. The length of hospital stay was shorter in the PEL group (8.0 ± 5.1 days vs 10.9 ± 5.8 days; mean ± SD; P < 0.001). Further, the PEL group was significantly younger (72.2 ± 12.1 vs 75.4 ± 13.1; mean ± SD; P = 0.036), had fewer patients with hypertension (62.0% vs 75.2%; P = 0.027) and malignant neoplasm (1.6% vs 10.6%; P = 0.002), and had better performance statuses (86.1% vs 76.1%; P = 0.047). Patients in the PEL group received fewer blood transfusions (25.6% vs 44.3%; P = 0.002), had a higher rate of cecal completion (88.3% vs 49.6%; P < 0.001), and shorter endoscopic observation times (20.8 ± 16.2 min vs 29.9 ± 24.8 min; mean ± SD; P = 0.006). After propensity score matching, there were 91 patients each in PEL group and in non-PEL group. PEL group had a significantly shorter hospital stay (7.9 ± 4.6 days vs 10.7 ± 5.8 days; mean ± SD; P < 0.001), a higher cecum completion rate (87.8% vs 48.3%; P < 0.001), and a shorter endoscopic observation time (20.7 ± 16.8 min vs 28.9 ± 24.1 min; mean ± SD; P = 0.031) than non-PEL group. There were no significant differences in blood transfusion requirements, rebleeding rates, identification of SRH, need for endoscopic hemostatic treatment, or complication rates.

Conclusion

In patients with CDB, urgent colonoscopy under PEL resulted in shorter hospital stays, higher cecal completion rates, and shorter endoscopic observation time in urgent colonoscopy. The safety of urgent colonoscopy with PEL was comparable to colonoscopy without PEL. These results suggest that PEL is preferrable for urgent colonoscopy in patients with CDB.

References

1. Nagata N, Kobayashi K, Yamauchi A, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study. Am J Gastroenterol 2021; 116: 2222-2234.
2. Aoki T, Nagata N, Shimbo T, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2.
3. Xavier SA, Machado FJ, Magalhães JT, et al. Acute lower gastrointestinal bleeding: are STRATE and BLEED scores valid in clinical practice? Colorectal Dis 2019; 21: 357-364.

Introduction

Motorized spiral enteroscopy (MSE) has shown to be safe and effective for deep small bowel enteroscopy in patients with and without prior abdominal surgery, including patients with Crohn’s disease.
This case series reports our first results regarding the feasibility and safety of the MSE with endoscopic balloon dilatation in patients with small bowel strictures due to Crohn’s disease.

Aims & Methods

Data were collected retrospectively on patients who underwent MSE for endoscopic balloon dilatation of small bowel strictures due to Crohn’s disease. Strictures were either postoperative (P.O.) or post-inflammatory (P.I.).

Results

A total of ten consecutive patients with Crohn’s disease underwent 13 procedures. Propofol sedation without endotracheal intubation was used in all procedures. Demographic and procedure related data are shown in the table. One patient underwent three procedures with 3–4 month intervals. During the third procedure triamcinolone acetonide was injected at four quadrants of the stricture. Fluorescence imaging was used during six procedures. The procedure was technically successful in 12/13 of procedures. In one case, dilatation was not performed because of a longer than anticipated and a sharply angulated stricture.
The number of treated strictures ranged from one to five per procedure. Dilatation of multiple strictures in two patients (4 and 5) was achieved within a relatively short procedure duration of 55 and 70 minutes. Two retained video capsules were retrieved.
Besides the anticipated mild abdominal discomfort and/or sore throat in three patients, no adverse events occurred.

Conclusion

These retrospective data show that MSE with CRE dilatation is feasible and safe in a cohort of patients with strictures due to Crohn’s disease, postoperatively as well as post-inflammatory. The fact that the distal 16 cm of the endoscope are not covered by the spiral overtube makes cautious introduction of the endoscope beyond a recently dilated stricture feasible and safe. Therefore, dilatation of multiple strictures in one session is possible, provided that they are at a short distance from each other. Fluorescence imaging guidance may be helpful in severe stenosis, multiple strictures, or sharp angulations.