Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors.

BACKGROUND & AIMS: Nonoperative methods for diagnosis of pancreas cysts often lack sufficient accuracy. Accurate diagnosis is needed to determine prognosis and guide clinical management. The aim of this study was to determine whether the tissue obtained by endoscopic ultrasound-guided trucut biopsy (EUS TCB) is sufficient for histologic diagnosis of cystic pancreatic tumors (CPTs). METHODS: EUS TCB was performed in patients with a suspected CPT. A dedicated gastrointestinal pathologist reviewed the core biopsies. The final diagnosis was based on clinical, laboratory, imaging, and biopsy findings, and resected specimens when available. RESULTS: EUS TCB was performed in 10 patients with a suspected CPT. Final diagnoses included serous cystadenoma (SCA, n=5), islet cell tumor (n=2), mixed seromucinous lesion (n=1), polycystic disease of the pancreas (n=1), and pseudocyst (n=1). EUS TCB was nondiagnostic in 3 of 10 patients. Among the other 7 patients, TCB diagnosed 4 SCAs, obviating the need for planned surgery in 3 patients. In the fourth patient with an SCA, the TCB result ruled out metastatic disease from locally recurrent lung cancer, allowing a narrowed radiation field. EUS TCB confirmed the need for surgery in 2 patients with an islet cell tumor. In 1 patient, EUS TCB findings were "partially" diagnostic, leading to previously unplanned surgery. CONCLUSIONS: This report establishes the capability and safety of EUS TCB to collect sufficient tissue for diagnosing CPTs. The results might help guide clinical management.     

Hemobilia caused by cytomegalovirus cholangiopathy

A 57-yr-old male on long-term steroid therapy presented with hematemesis, fever, and a retroperitoneal fluid collection. Hemobilia was diagnosed, but the cause was not identified by ERCP, computed tomography, or angiography. Peroral cholangioscopy revealed multiple biliary ulcers. Cholangioscopic biopsies diagnosed cytomegalovirus (CMV) infection. Intravenous ganciclovir therapy was initiated, and was associated with cessation of bleeding. Biliary CMV disease is rare in HIV-negative persons, but should be considered in a patient with unexplained hemobilia. Cholangioscopy may be useful for diagnosis.     

EUS diagnosis of vascular invasion in pancreatic cancer: surgical and histologic correlates

BACKGROUND: Endoscopic ultrasound (EUS) has been compared to intraoperative surgical palpation for diagnosis of vascular invasion by pancreatic cancer. This study compares EUS with vascular resection and histologic evidence of vascular invasion in resected pancreatic masses. METHODS: All patients with solid pancreatic masses who underwent both preoperative EUS and surgery at 1 hospital over a 7 year period were identified. The relationship of pancreatic masses to adjacent vessels was prospectively assessed by EUS. EUS findings were compared to surgical and pathology gold standards. "Vascular adherence" was defined as tumor adherence requiring vascular resection during surgery, and "vascular invasion" as histologic invasion of vessel wall by tumor. RESULTS: 30 of 68 patients were resectable. Among these 30, vascular adherence was present in 8, including 18% of patients with an intact echoplane between tumor and adjacent vessels at EUS, 29% of those with loss of echoplane alone, and 50% of those with additional EUS features of vascular involvement. Vascular invasion was present in 4, including 12% of patients with an intact echoplane, 0% of those with loss of echoplane alone, and 33% of those with additional EUS features. Sensitivity, specificity, PPV, and NPV of EUS were 63%, 64%, 43% and 80% for vascular adherence and 50% 58%, 28% and 82% for vascular invasion. NPV rose to 90% for vascular adherence if only the portal confluence vessels were considered. CONCLUSIONS: EUS has poor sensitivity, specificity, and positive predictive value for diagnosis of venous involvement by pancreatic cancer.     

Self-expanding plastic stents in treatment of benign esophageal conditions

BACKGROUND: Recently, self-expanding plastic stents (SEPSs) have been proposed for the treatment of benign esophageal disease. OBJECTIVES: Our purpose was to review our experience with SEPSs in patients with benign esophageal conditions. DESIGN: This was a retrospective case review of patients who underwent SEPS placement for benign esophageal disease, including (1) benign stricture, including reflux disease, ischemia, and idiopathic, (2) radiation-induced strictures, (3) anastomotic strictures, and (4) esophageal leak/fistulae. PATIENTS: Nineteen male and 11 female patients (average age 52.1 years, range 11-87 years) underwent SEPS placement. INTERVENTIONS: SEPS placement. MAIN OUTCOME MEASUREMENTS: Initial complications, stent migration, long-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging. RESULTS: Eighty-three of 84 SEPS placements were successful. The most common complications were chest pain, dysphagia, nausea, and vomiting. No deaths were reported from stent placement. Stent migration was more frequent in proximal (30/44 stents, 68.1%) and distal (19/27 stents, 70.4%) compared with mid esophageal (3/10 stents, 30%). Migration was more frequent in stents placed for benign strictures (18/22 stents, 81.8%), anastomotic strictures (18/24 stents, 75%), and fistulae/leak (13/22 stents, 59.1%) compared with radiation-induced strictures (4/14 stents, 28.6%). Only 5 of 83 interventions (6%) resulted in long-term improvement after stent removal. LIMITATIONS: This was a retrospective review, and patients were selected from a tertiary medical center. CONCLUSION: Use of SEPSs for benign esophageal conditions resulted in frequent stent migration and few cases of long-term improvement. Further investigation is warranted to identify optimal patient populations and to guide future recommendations for the use of SEPSs.     

Temporomandibular joint adaptations following maxillary osteotomy in adolescent monkeys

The purpose of this study was to investigate the histologic appearance of temporomandibular joints of monkeys who had undergone total maxillary osteotomy. The specific aim of the study was to seek clues that might explain the inhibition in the mandibular growth 27 months following the surgery performed on adolescent monkeys. Eighteen female adolescent Macaca fascicularis monkeys were used. Eight served as control and ten were experimental. All experimental animals underwent 3.0 to 5.0 mm superior and 0.5 to 2.5 mm anterior repositioning of the maxilla. All animals were killed 27 months after the surgical procedure. Qualitative and quantitative histologic evaluations of the temporomandibular joints were done and results were compared with the cephalometric data. The findings showed no pathologic changes, although the histologic appearance of the temporomandibular joints of the experimental animals was more mature than that of the controls. The histologic results support cephalometric findings and the data are discussed in relationship to the role of maxilla, maxillary teeth, and occlusion in regulating mandibular growth.