Faculty Bibliography

Background and Study Aims: Fluorescent in-situ hybridization (FISH) performed on brush specimens is one of the most accurate and widely used second line diagnostic modalities. Our goal was to compare the diagnostic accuracy of FISH in the detection of malignancy compared with other standard diagnostic modalities, including brush cytology and biopsy specimens over a ten year period of prospective data collection. Patients and methods: We conducted a review of a prospectively maintained database of biliary strictures between 2006 and 2016. Patients with a final pathologic diagnosis or a conclusive follow-up were included. Cytology and biopsy results were considered positive for malignancy when suspicious or malignant cells were identified. We evaluated the performance of FISH polysomy (CEP 3, 7, and 17) and 9p21 deletion. Statistical analysis was performed with the Chi square and Fisher exact tests. Results: Of 382 who underwent evaluation for biliary strictures, 277 met inclusion criteria. 119 patients (42.8%) were found to have malignancy (58.0% pancreatic cancer, 37.0% cholangiocarcinoma, 5.0% other malignancies). Benign etiology included inflammatory strictures (63.9%), PSC (19.6%), post-operative (6.3%) or other benign etiologies (10.2%). The sensitivities for FISH and cytology were found to be 55.4% and 39.0%. Both cytology and FISH showed a very high specificity of 99.4%. The accuracy and AUC of FISH polysomy and cytology (AUC=.789) was significantly higher than cytology alone (AUC=.688; p<0.05). The addition of detection of 9p21 deletion led to no additional false positives but an additional diagnosis of 11/119 (9.2%) malignant cases, however there was a nonsignificant difference in the accuracy and AUC of FISH polysomy versus FISH polysomy plus 9p21 deletion. The combination of brush cytology, FISH polysomy and 9p21 deletion and any additional sampling (i.e. biopsy) taken during ERCP showed a sensitivity of 70.0% that was not significantly higher than cytology plus FISH polysomy. There were 36 (30.3 %) patients who had malignancies that were undetected by any of the diagnostic modalities studied. Conclusion: This is the largest prospective cohort of patients with biliary strictures evaluated by FISH. The very high specificity of FISH polysomy and 9p21 deletion suggests that a positive result is sufficient for the diagnosis of biliary malignancy. A limitation of our data is the relatively small number of PSC patients where specificity may be lower. The significantly higher sensitivity of both FISH polysomy and polysomy or 9p21 deletion compared to cytology and the non-significant improvement in sensitivity when combing further sampling methods supports the use of FISH as first line in the evaluation of cytology negative strictures. (Table Presented)

Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.

BACKGROUND & AIMS:Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. METHODS:We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. RESULTS:The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). CONCLUSIONS:On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that carry a risk of malignant transformation to pancreatic ductal adenocarcinoma (PDAC). Guidelines have been evolving to best identify which criteria should qualify a patient for resection and which cysts can safely remain under surveillance. Our aim was to understand which baseline cyst and patient features predict disease progression and malignant transformation. Aims & Methods: Patients with clinically suspected IPMN who did not meet consensus criteria for resection at diagnosis and were surveyed for at least 12 months or underwent surgery after a minimum surveillance of 3 months were included. All patients evaluated by radiologic studies or endoscopic ultrasound between 1998 and 2015 were included. We defined progression as either an increase in size of the dominant cyst >=20% or >=2mm or the development of worrisome features (mural nodule or mass, thick septations, main duct involvement or high grade dysplasia or cancer on cytology or surgical pathology). Statistical analysis was performed with the Chi square and Fisher exact tests for categorical variables and Mann-Whitney U test for continuous variables. All covariates of interest with p<0.05 in the univariate analysis were included in the logistic regression model. Result: male gender, a history of prostate cancer and diabetes, weight loss and initial cyst size >2 cm. A history of prostate cancer, diabetes, weight loss, elevated cyst fluid CEA and cyst size >2 cm were associated with development of worrisome features. In logistic regression analysis, a history of prostate cancer (OR 2.9; 95% CI 1.7-7.7) and weight loss (OR 2.47; 95% CI 1.18-6.1) were associated with development of worrisome features (p<0.05). There were no baseline predictors of cyst size increase alone. Baseline characteristics such as race, smoking or alcohol use, a strong family history of PDAC, multifocality and location of cysts were not associated with increased disease progression. Conclusion: In the largest multicenter surveillance study of low risk IPMNs to date, we showed that 41% of suspected IPMNs increased in size only, 9% developed worrisome features and 2% developed high-grade dysplasia or cancer. Among baseline characteristics, none were predictive of size increase. A personal history of prostate cancer and weight loss were the strongest predictors of the development of worrisome features. (Table Presented)

BACKGROUND AND STUDY AIMS: Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome. PATIENTS AND METHODS: This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared. RESULTS: A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups. CONCLUSIONS: Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration.

GOALS: To describe a multicenter experience using an endoscopic suturing device for management of gastrointestinal (GI) defects and stent anchorage. BACKGROUND: Endoscopic closure of GI defects including perforations, fistulas, and anastomotic leaks as well as stent anchorage has improved with technological advances. An endoscopic suturing device (OverStitch; Apollo Endosurgery Inc.) has been used. STUDY: Retrospective study of consecutive patients who underwent endoscopic suturing for management of GI defects and/or stent anchorage were enrolled between March 2012 and January 2014 at multiple academic medical centers. Data regarding demographic information and outcomes including long-term success were collected. RESULTS: One hundred and twenty-two patients (mean age, 52.6 y; 64.2% females) underwent endoscopic suturing at 8 centers for stent anchorage (n=47; 38.5%), fistulas (n=40; 32.7%), leaks (n=15; 12.3%), and perforations (n=20; 16.4%). A total of 44.2% underwent prior therapy and 97.5% achieved technical success. Immediate clinical success was achieved in 79.5%. Long-term clinical success was noted in 78.8% with mean follow-up of 68 days. Clinical success was 91.4% in stent anchorage, 93% in perforations, 80% in fistulas, but only 27% in anastomotic leak closure. CONCLUSIONS: Endoscopic suturing for management of GI defects and stent anchoring is safe and efficacious. Stent migration after stent anchoring was reduced compared with published data. Long-term success without further intervention was achieved in the majority of patients. The role of endoscopic suturing for repair of anastomotic leaks remains unclear given limited success in this retrospective study.

OBJECTIVES/OBJECTIVE:Intraductal papillary mucinous neoplasms (IPMNs) are premalignant pancreatic cysts commonly found incidentally. Immunosuppression accelerates carcinogenesis.Thus, we aimed to compare IPMN progression in liver transplant (LT) recipients on chronic immunosuppression to progression among an immunocompetent population. METHODS:We retrospectively assessed adult LT recipients between 2008 and 2014 for imaging evidence of IPMN. Diagnosis of IPMN was based on history, imaging, and cyst fluid analysis. The immunocompetent control group consisted of nontransplant patients from our pancreatic cyst surveillance program with IPMN under surveillance for greater than 12 months between 1997 and 2013. Four hundred fifty-four patients underwent LT in the study period and had cross-sectional imaging. RESULTS:The prevalence of suspected IPMN was 6.6% (30 of 454). Compared with 131 controls, the transplant cohort was younger, with increased prevalence of diabetes and smoking. The prevalence of other risk factors for IPMN progression (history of pancreatitis, family history of pancreatic cancer) was similar. After an average follow-up of 31 months, most cysts increased in diameter, with a similar increase of dominant cyst (0.4 cm vs 0.5 cm; P = 0.6). Type of immunosuppression was not associated with the increased rate of cyst growth. CONCLUSIONS:Our findings suggest that LT recipients with incidental IPMN can be managed under similar guidelines as immunocompetent patients.