Endoscopic ultrasonography-guided fine needle aspiration:Relatively low sensitivity in the endosonographer population

AIM： To assess the characteristics and quality of endoscopic ultrasonography-guided fine needle aspiration （EUS-FNA） in a large panel of endosonographers.METHODS： A survey was conducted during the 13th annual live course of endoscopic ultrasonography （EUS） held in Amsterdam, Netherlands. A 2-page question- naire was developed for the study. Content validity of the questionnaire was determined based on input by experts in the field and a review of the relevant literature. It contained 30 questions that pertained to demographics and the current practice for EUS-FNA of responders, including sampling technique, sample processing, cytopathological diagnosis and sensitivity of EUS-FNA for the diagnosis of solid mass lesions. One hundred and sixty-one endosonographers whoattended the course were asked to answer the survey. This allowed assessing the current practice of EUS-FNA as well as the self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions. We also examined which factors were associated with a self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions 〉 80%.RESULTS： Completed surveys were collected from 92 （57.1%） of 161 endosonographers who attended the conference. The endosonographers had been practio ing endoscopy and EUS for 22.5 4. 7.8 years and 4.8 4- 4.1 years, respectively; one third of them worked in a hospital with an annual caseload 〉 100 EUS-FNA. Endoscopy practices were located in 29 countries, in- cluding 13 countries in Western Europe that totaled 75.3% of the responses. Only one third of endosonog raphers reported a sensitivity for the diagnosis of solid mass lesions 〉 80% （interquartile range of sensitivities, 25.0%-75.0%）. Factors independently associated with a sensitivity 〉 80% were （1） 〉 7 needle passes for pancreatic lesions or rapid on-site cytopathological evaluation （ROSE） （P 〈 0.0001）, （2） a high annual hospital caseload （P = 0.024） and （3） routine isolation of microcores from EUS-FNA samples （P = 0.042）. ROSE was routinely available to 27.9% of respondents. For lymph nodes and pancreatic masses, a maximum of three needle passes was performed by approximately two thirds of those who did not have ROSE. Microcores were routinely harvested from EUS-FNA samples by approximately one third （37.2%） of survey respondents.CONCLUSION： EUS-FNA sensitivity was considerably lower than reported in the literature. Low EUS-FNA sensitivity was associated with unavailability of ROSE, few needle passes, absence of microcore isolation and low hospital caseload.

Self-expandable metal stents for malignant gastric outlet obstruction: A pooled analysis of prospective literature

AIM: To provide an overview of the clinical outcomes of self-expandable metal stent(SEMS) placement for malignant gastric outlet obstruction(MGOO).METHODS: A systematic literature search was performed in Pub Med of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success,defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs(PCSEMSs) and uncovered SEMSs(UCSEMSs) using Fisher's exact test.RESULTS: A total of 19 studies,including 1281 patients,were included in the final analysis. Gastric(42%) and pancreatic(37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients,mainly caused by re-obstruction(12.6%) and stent migration(4.3%),and was comparable between PCSEMSs and UCSEMSs(21.2% vs 19.1%,respectively,P = 0.412). Re-obstruction was more common with UCSEMSs(14.9% vs 5.1%,P < 0.001) and stent migration was more frequent after PCSEMS placement(10.9% vs 2.2%,P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients,including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies.CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible,effective and safe. Therefore,stent placement is a valid treatment option for the palliation of MGOO.

Adherence to surveillance guidelines for dysplasia and colorectal carcinoma in ulcerative and Crohn's colitis patients in the Netherlands

AIM: To study adherence to the widely accepted surveillance guidelines for patients with long-standing colitis in the Netherlands. METHODS: A questionnaire was sent to all 244 gastroenterologists in the Netherlands. RESULTS: The response rate was 63%. Of all gastroenterologists, 95% performed endoscopic surveillance in ulcerative colitis (UC) patients and 65% in patients with Crohn's colitis. The American Gastroenterological Association (AGA) guidelines were followed by 27%, while 27% and 46% followed their local hospital protocol or no specific protocol, respectively. The surveillance was correctly initiated in cases of pancolitis by 53%, and in cases of left-sided colitis by 44% of the gastroenterologists. Although guidelines recommend 4 biopsies every 10 cm, less than 30 biopsies per colonoscopy were taken by 73% of the responders. Only 31%, 68% and 58% of the gastroenterologists referred patients for colectomy when low-grade dysplasia, high-grade dysplasia (HGD) or Dysplasia Associated Lesion or Mass (DALM) was present, respectively. CONCLUSION: Most Dutch gastroenterologists performendoscopic surveillance without following international recommended guidelines. This practice potentially leads to a decreased sensitivity for dysplasia, rendering screening for colorectal cancer in this population highly ineffective.

Biliary drainage of the common bile duct with an enteral metal stent

In this case report we present an elderly patient who was referred to our hospital with recurrent episodes of cholangitis that persisted after placement of fi ve metal stents for a distal common bile duct(CBD) stenosis.All metal stents were endoscopically removed from the CBD by forceps after balloon dilatation of the papilla.A profoundly dilated CBD with sludge and concrements was seen.To ensure adequate bile drainage an enteral metal stent was inserted in the CBD.This case shows that proximally migrated uncovered metal stents in the CBD can be safely removed endoscopically under certain circumstances.We suggest that in the case of a CBD drainage problem due to an extremely dilated CBD,placement of an enteral metal stent in the CBD could be considered,especially in patients who are unfi t for surgery.

Similar fecal immunochemical test results in screening and referral colorectal cancer

AIM: To improve the interpretation of fecal immunochemical test (FIT) results in colorectal cancer (CRC) cases from screening and referral cohorts. METHODS: In this comparative observational study, two prospective cohorts of CRC cases were compared. The first cohort was obtained from 10 322 average risk subjects invited for CRC screening with FIT, of which, only subjects with a positive FIT were referred for colonoscopy. The second cohort was obtained from 3637 subjects scheduled for elective colonoscopy with a positive FIT result. The same FIT and positivity threshold (OC sensor; ≥ 50 ng/mL) was used in both cohorts. Colonoscopy was performed in all referral subjects and in FIT positive screening subjects. All CRC cases were selected from both cohorts. Outcome measurements were mean FIT results and FIT scores per tissue tumor stage (T stage). RESULTS: One hundred and eighteen patients with CRC were included in the present study: 28 cases obtained from the screening cohort (64% male; mean age 65 years, SD 6.5) and 90 cases obtained from the referral cohort (58% male; mean age 69 years, SD 9.8). The mean FIT results found were higher in the referral cohort (829 ± 302 ng/mLvs 613 ± 368 ng/mL,P = 0.02). Tissue tumor stage (T stage) distribution was dif-ferent between both populations [screening population: 13 (46%) T1, eight (29%) T2, six (21%) T3, one (4%) T4 carcinoma; referral population: 12 (13%) T1, 22 (24%) T2, 52 (58%) T3, four (4%) T4 carcinoma], and higher T stage was significantly associated with higher FIT results (P < 0.001). Per tumor stage, no significant difference in mean FIT results was observed (screening vs referral: T1 498 ± 382 ng/mL vs 725 ± 374 ng/mL, P = 0.22; T2 787 ± 303 ng/mL vs 794 ± 341 ng/mL, P = 0.79; T3 563 ± 368 ng/mLvs 870 ± 258 ng/mL,P = 0.13; T4 not available). After correction for T stage in logistic regression analysis, no significant differences in mean FIT results were observed between both types of cohorts (P = 0.10). CONCLUSION: Differences in T stage distribution largely explain differences in FIT results between screening and referral cohorts. Therefore, FIT results should be reported according to T stage.

SATB1 Protein Is Associated with a More Aggressive Phenotype of Sporadic Colorectal Cancer

Background: Experimental studies have shown that cyclo-oxygenase-2 (Cox2) is related to the development and progression of tumors, since this enzyme is induced and expressed by cells such as macrophages, osteoblasts, “activated” endothelial cells, and tumor cells. The activity in tumors includes proliferation, cell transformation, tumor growth, invasion and metastasis and may play an important role in carcinogenesis of the canine osteosarcoma, since it has high expression in tissue fragments. The combination of selective Cox2 inhibitors and other treatment modalities is the basis for a new anti-cancer therapy strategy. This in vitro study exposed primary cells of five different canine osteosarcoma cultures to selective Cox2 inhibitor at increasing concentrations and times. Results: For Cox2 negative cultures, despite the absence of differences, greater sensitivity of cells to treatment was observed. For Cox2 positive cultures, a higher number of necrotic cells were observed (P ≤ 0.05), when compared with negative cultures. For exposure times with Celecoxib doses, no difference (P > 0.05) was found between the three times analyzed for living, apoptotic and apop- totic/necrotic cells. There are similarities in the values of 24 h and 48 h, with slight reduction of living cells, increasing those undergoing apoptosis and apoptosis/necrosis. There was significance for necrosis (P ≤ 0.05). In 72 hours, a significant difference was observed between the other two previous values (P ≤ 0.05). It was found for the group of 100 μM?L?1, that there was a numerically greater signaling for apoptosis and lower (P = 0.08) for necrosis, and this point was the onset of the pharmacodynamic phenomenon, with drop in the values for living cells and increased number of necrotic cells, with a tendency (P = 0.08) for reducing the percentage of necrotic cells for the group of 100 μM?L?1 when compared to that of 10 μM?L?1. Conclusions: For Cox2 positive and negative cultures, there was difference for necrotic cells and there was no difference between Cox2 positive and Cox2 negative groups in relation to the percentage of living cells and apoptotic and apoptotic/necrotic cells. At time of 72 hours, higher percentage of living cells, lower percentage of apoptotic cells and increased percentage of necrotic cells in relation to groups of 24 and 48 hours were observed. A tendency for reducing the percentage of necrotic cells for the group of 100 μM?L?1 when compared to that of the group of 10 μM?L?1 was observed.

较大直肠腺瘤中经肛门内镜显微手术与内镜下黏膜切除术的随机对照试验(TREND研究)

摘要 目的 非随机研究表明内镜下黏膜切除术(endoscopic mucosal resection,EMR)在切除直肠较大腺瘤时与经肛门内镜显微手术(transanal endoscopic microsurgery,TEM)同样有效,但EMR可能更具成本效益且相对安全。本试验旨在对比摘除较大直肠腺瘤时EMR与TEM的临床结局与成本效益。