A Prospective Comparison of EUS-Guided FNA Using 25-Gauge and 22-Gauge Needles

Background and Aims. There are limited data on the differences in diagnostic yield between 25-gauge and 22-gauge EUS-FNA needles. This prospective study compared the difference in diagnostic yield between a 22-gauge and a 25-gauge needle when performing EUS-FNA. Methods. Forty-three patients with intraluminal or extraluminal mass lesions and/or lymphadenopathy were enrolled prospectively. EUS-FNA was performed for each mass lesion using both 25- and 22-gauge needles. The differences in accuracy rate, scoring of needle visibility, ease of puncture and quantity of obtained specimen were evaluated. Results. The overall accuracy of 22- and 25-gauge needle was similar at 81% and 76% respectively (N.S). Likewise the visibility scores of both needles were also similar. Overall the quantity of specimen obtained higher with the 22-gauge needle (score: 1.64 vs. P < .001). However the 25-gauge needle was significantly superior to the 22-gauge needle in terms of ease of puncture (score: 1.9 vs. 1.29, P < .001) and in the quantity of specimen in the context of pancreatic mass EUS-FNA (score: 1.8 vs. 1.58, P < .05). Conclusion. The 22-gauge and 25-gauge needles have similar overall diagnostic yield. The 25-gauge needle appeared superior in the subset of patients with hard lesions and pancreatic masses

Is endoscopic necrosectomy the way to go?

Pancreatic necrosis with the formation of walled-off collections is a known complication of severe acute pancreatitis. Infected necrotic pancreatic collections are associated with a high mortality rate. Open necrosectomy and debridement with closed drainage has traditionally been the gold standard for treatment of infected pancreatic necrosis, but carries a high risk of perioperative complications. Direct endoscopic necrosectomy has emerged as a safe and effective modality of treatment for this condition. Careful patient selection and gentle meticulous debridement is important to optimize clinical success. Bleeding is the commonest associated complication with the procedure but most cases can be managed conservatively. Air embolism, although rare, is potentially fatal. The use of fully covered large diameter lumen apposing self-expandable metal stents has further simplified the procedure. These stents optimize drainage, and facilitate endoscopic necrosectomy because repeat insertion of the endoscope into the necrotic cavity can be easily achieved

The Role of Endoscopy in the Management of Cystic Pancreatic Lesions

Pancreatic cystic lesions may be due to pseudocysts and related inflammatory fluid collections, simple cysts, cystic tumours such as serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm, as well as solid tumours with areas of cystic degeneration. The main diagnostic challenge is to distinguish premalignant and malignant cystic lesions from benign cystic lesions. Cross-sectional imaging using computer tomography and magnetic resonance imaging/ magnetic resonance cholangiopancreatography provides the initial morphological characterization. Endoscopic ultrasound (EUS) is an important tool when diagnostic doubts persist and is crucial in the assessment of invasive malignancy. EUS-guided fine needle aspiration and cyst fluid analysis has been shown to be cost-effective for risk stratifying the malignant potential of cystic tumours and the need for surgical resection. In the management of symptomatic pseudocysts and related fluid collections, endoscopic drainage has been established as the preferred technique, with efficacy similar to surgery but lower costs and morbidity

Current Status of Direct Endoscopic Necrosectomy

The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy