Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions:A single-center study

BACKGROUND Currently,there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions(PCLs),especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy(mFB)and needle-based confocal laser-endomicroscopy(nCLE).AIM To compare the accuracy of endoscopic ultrasound(EUS)and associated techniques for the detection of potentially malignant PCLs:EUS-guided fine needle aspiration(EUS-FNA),contrast-enhanced EUS(CE-EUS),EUS-guided fiberoptic probe cystoscopy(cystoscopy),mFB,and nCLE.METHODS This was a single-center,retrospective study.We identified patients who had undergone EUS,with or without additional diagnostic techniques,and had been diagnosed with PCLs.We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUSguided techniques and/or EUS-guided biopsy when available(EUS malignancy detection).RESULTS A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients,EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy(27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques thanEUS alone [62/82 (75.6%) vs 8/47 (17%);OR 4.35, 95%CI: 2.70-7.37;P < 0.001]. The highestmalignancy detection accuracy was reached when nCLE and direct intracystic mFB were bothperformed, with a sensitivity, specificity, positive predictive value, negative predictive value andobserved agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 comparedwith EUS-alone).CONCLUSIONThe combined use of EUS-guided mFB and nCLE improves detection of potentially malignantPCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.

High-definition optical magnification with digital chromoendoscopy detects gastric mucosal changes in dyspeptic-patients

BACKGROUND Accurate detection of gastric infection by Helicobacter pylori(H.pylori)and premalignant lesions are important for effective provision of treatment,preventing the development of gastric neoplasia.Optical enhancement systems with optical magnification improved the identification of mucosal superficial and vascular patterns in patients with dyspepsia.AIM To evaluate an optical enhancement system with high-definition magnification,for diagnosis of normal gastric mucosa,H.pylori-associated gastritis,and gastric atrophy.METHODS A cross-sectional,nonrandomized study from November 2015 to April 2016 performed in a single-tertiary academic center from Ecuador.Seventy-two consecutive patients with functional dyspepsia according to the Rome III criteria,were tested for H.pylori using a stool antigen test and were assigned to an Hp+group or an Hp−control group.Esophagogastroduodenoscopy with highdefinition optical magnification and digital chromoendoscopy was performed,and patients were classified into 4 groups,in accordance to the microvasculararchitecture pattern of the mucosa.Interobserver and intraobserver agreement among operators were calculated.RESULTS Of the 72 participants,35 were Hp+and 37 were Hp−.Among 10 patients with normal mucosal histology in biopsy samples,90%had a Type I pattern of microvascular architecture by endoscopy.Among participants with type IIa and type IIb patterns,significantly more were Hp+than Hp−(32 vs 8),and most(31 out of 40)had histological diagnoses of chronic active gastritis.Two of the three participants with a histological diagnosis of atrophy had a type III microvascular pattern.The type I pattern predicted normal mucosa,type IIa–IIb predicted H.pylori infection,and type III predicted atrophy with sensitivities of 90.0%,91.4%,and 66.7%,respectively.The intraobserver and interobserver agreements had kappa values of 0.91 and 0.89,respectively.CONCLUSION High-definition optical magnification with digital chromoendoscopy is useful for diagnosis of normal gastric mucosa and H.pylori-associated gastritis with high accuracy,but further studies are needed to determine whether endoscopic diagnosis of gastric atrophy is feasible.

Clinical impact of confocal laser endomicroscopy in the management of gastrointestinal lesions with an uncertain diagnosis

AIM To evaluate the clinical impact of confocal laser endomicroscopy(CLE) in the diagnosis and management of patients with an uncertain diagnosis.METHODS A retrospective chart review was performed.Patients who underwent CLE between November 2013 and October 2015 and exhibited a poor correlation between endoscopic and histological findings were included.Baseline characteristics,indications,previous diagnostic studies,findings at the time of CLE,clinical management and histological results were analyzed.Interventions based on CLE findings were also analyzed.We compared the diagnostic accuracy of CLE and target biopsies of surgical specimens.RESULTS A total of 144 patients were included.Of these,51%(74/144) were female.The mean age was 51 years old.In all,41/144(28.4%) lesions were neoplastic(13 bile duct,10 gastric,8 esophageal,6 colonic,1 duodenal,1 rectal,1 ampulloma and 1 pancreatic).The sensitivity,specificity,positive predictive value,negative predictive value,and observed agreement when CLE was used to detect N-lesions were 85.37%,87.38%,72.92%,93.75% and 86.81%,respectively.Cohen's Kappa was 69.20%,thus indicating good agreement.Changes in management were observed in 54% of the cases.CONCLUSION CLE is a new diagnostic tool that has a significant clinical impact on the diagnosis and treatment of patients with uncertain diagnosis.

Cost-effectiveness of endoscopic ultrasound-guided coils plus cyanoacrylate injection compared to endoscopic cyanoacrylate injection in the management of gastric varices

BACKGROUND Cyanoacrylate(CYA)injection can be performed using a standard upper endoscopy technique or under endoscopic ultrasound(EUS)guidance alone or in combination with coils.There is little information available on the economic impact of these treatment methods.AIM To compare the cost-effectiveness of treating gastric varices by CYA injection via upper endoscopy vs coils plus CYA guided by EUS.METHODS This was an observational,descriptive,and retrospective study.Patients were allocated into two groups:A CYA group and coils plus CYA group.The baseline characteristics were compared,and a cost analysis was performed.RESULTS Overall,36 patients were included(19 in the CYA group and 17 in the coils+CYA group).All patients in the CYA group had acute bleeding.They underwent a higher mean number of procedures(1.47 vs 1,P=0.025),and the mean volume of glue used was 2.15 vs 1.65 mL,P=0.133.The coils+CYA group showed a higher technical success rate(100%vs 84.2%),with a complication rate similar to the CYA group.The majority of CYA patients required hospitalization,and although the mean total per procedure cost was lower(United States$1350.29 vs United States$2978),the mean total treatment cost was significantly different(United States$11060.89 for CYA vs United States$3007.13 for coils+CYA,P=0.03).CONCLUSION The use of EUS-guided coils plus cyanoacrylate is more cost-effective than cyanoacrylate injection when the total costs are evaluated.Larger,randomized trials are needed to validate the cost-effectiveness of the EUS-guided approach to treat gastric varices.

Confocal endomicroscopy:Is it time to move on?

Confocal laser endomicroscopy permits in-vivo microscopy evaluation during endoscopy procedures. It can be used in all the parts of the gastrointestinal tract and includes: Esophagus,stomach,small bowel,colon,biliary tract through and endoscopic retrograde cholangiopancreatography and pancreas through needles during endoscopic ultrasound procedures. Many researches demonstrated a high correlation of results between confocal laser endomicroscopy and histopathology in the diagnosis of gastrointestinal lesions; with accuracy in about 86% to 96%. Moreover,in spite that histopathology remains the gold-standard technique for final diagnosis of any diseases; a considerable number of misdiagnosis rate could be present due to many factors such as interpretation mistakes,biopsy site inaccuracy,or number of biopsies. Theoretically; with the diagnostic accuracy rates of confocal laser endomicroscopy could help in a daily practice to improve diagnosis and treatment management of the patients. However,it is still not routinely used in the clinical practice due to many factors such as cost of the procedure,lack of codification and reimbursement in some countries,absence of standard of care indications,availability,physician imageinterpretation training,medico-legal problems,and the role of the pathologist. These limitations are relative,and solutions could be found based on new researches focused to solve these barriers.