[Show abstract][Hide abstract] ABSTRACT: Introduction: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become widely accepted as an effective, minimally invasive diagnostic tool for the evaluation of solid and cystic lesions of the gastrointestinal (GI) and respiratory tract. Although an increasing number of major tertiary centres have adopted EUS-FNA as a standard diagnostic tool, the availability of EUS-FNA in regional areas is still limited. To our knowledge, there are currently no reports on its performance in this setting in the literature. EUS was first introduced in our regional 300-bed hospital servicing Northern Tasmania in 2013. Here we report our single-operator experience with EUS-FNA with regard to clinical utility, diagnostic accuracy, and safety. Methods: Data was prospectively collected on consecutive EUS procedures performed at the Launceston General Hospital between January and October 2013. Patient demographics and the operating characteristics of EUS-FNA were recorded. Final diagnosis was based on a composite standard: histologic evidence at surgery, or non-equivocal cytology on FNA and follow-up. Results:A total of 100 EUS examinations with 64 EUS-FNA were performed during the study period (34 men, mean age 69.1 years, range 39-89). These included 28 solid pancreatic lesions, 8 cystic pancreatic lesions, 14 lymph nodes, 7 subepithel- ial GI lesions, and 7 intra-abdominal or mediastinal lesions (see figure 1). 25-gauge needle was used in 57 cases, and 22-gauge needle in 7 cases. Mean solid lesion size was 29.5 mm
(range 5-45mm) with a median of 2 needle passes per lesion (range 1-4) to obtain a diagnosis. Adequate material, as assessed by in-room cytopathologist, was obtained from all solid pancreatic lesions, lymph nodes, and 6 of 7 subepithelial GI lesions. Malignant pathology was diagnosed in 85.7, 78.6, and 85.7% of cases respectively. EUS-FNA was highly sensitive and accurate for solid pancreatic lesions (91.7 and 92.86% respectively). Cyst fluid was assessed by well-establish criteria with 3 of 8 lesions (37.5%) being highly suspicious for malignancy (see table 1). No minor or major complications occurred during the study period. Conclusions: Our experience confirms that EUS-FNA can be safely and effectively performed while maintaining high diagnostic accuracy in a regional centre. Technical success approaches 100%, with yield from solid lesions in excess of 90%. We propose that EUS be utilised more frequently in regional centres, and be considered the preferred test when a cytological diagnosis is required.
[Show abstract][Hide abstract] ABSTRACT: Background and aims: The novel over-the-scope-clip (OTSC; Ovesco Endoscopy GmbH, Tübingen, Germany) has been reported as an effective method for management of upper gastrointestinal bleeding and luminal perforation or fistula. Several recent international publications examined short and long term efficacy of OTSC. This retrospective case series aims to assess the early results after introduction of OTSC in a regional Australian Hospital.
Methods: Launceston General Hospital is a major 308 bed regional hospital servicing Northern Tasmania. We interrogated a prospectively maintained endoscopic database of all patients who underwent Gastroscopy(OGD) from March 2012, and identified those cases where an OTSC was used. Medical charts were reviewed, and where appropriate patients were contacted. We assessed primary haemostasis, complications, mortality, and blood count at week 1 and 4 following the application of OTSC.
Results: A total of 1444 OGDs were performed during the study period. Of these, 48 were performed for the indication of acute gastrointestinal bleeding and 4 for the management of perforations or fistulas. The OTSC was utilized in five cases (age 59-92 years, mean age: 77.4, mean admission Haemoglobin of 64 g/L) by two interventional endoscopists. Four patients had haemodynamically unstable upper gastrointestinal bleeding ( Including a Gastric Dieulafoy, Duodenal ulcer, perforated Duodenal ulcer, and Mallory-Weiss tear) with a mean transfusion requirement of 5 units per patient. All patients failed conventional haemostatic measures with Adrenaline, Gold probe, and Endoscopic clips. Primary haemostasis was achieved with OTSC in 100% of cases. Bleeding recurred in one patient with a giant 20mm perforated duodenal ulcer on day 1. Unfortunately this patient died due to complications of premorbid anuric acute kidney injury and multi-organ failure after surgical intervention. Repeat haemoglobin levels at weeks 1 and 4 were stable in the other cases of major bleeding successfully treated with OTSC. One OTSC was also used unsuccessfully in an attempt to close a large gastric perforation following surgical hiatus hernia repair and fundoplication
Conclusion: In our retrospective case series, the OTSC appears to be an effective therapeutic modality for acute upper gastrointestinal bleeding in patients when conventional endoscopic haemostatic measures fail. We find it to be a particularly valuable tool in our regional centre. It might also be particularly useful in patients with significant medical comorbidities deemed inappropriate for surgery. OTSC use in patients with gastrointestinal perforation warrants further study.
Australian Gastroenterological Week 2012, Melbourne; 10/2013