We are reporting a case of failed ERCP for a patient with cholangitis complicating ampullary adenoma. EUS was used as salvage for cannulation of the CBD. After several trials of wire RDV, Methylene Blue was injected and the flow from the papilla could easily serve as guide for identification of the papillary orifice.

EUS guided injection of Methylene Blue could offer a safe and easy approach for identification of the ampullary orifice if ERCP fails as well as wire RDV.

Endoscopic biliary drainage remains the standard palliative treatment in neoplastic biliary stenosis in patients not operated. The objective of our study is to retrospectively specify the results of this technique in our training, as well as the various factors associated with its failure or success.Materials and MethodsJanuary 2009 to September 2017,105 patients with biliary stenosis of neoplastic origin were included. Patients were divided into 3 groups:"A" for patients with proximal cholangiocarcinoma, group "B" for patients with pancreatic cancer, group "C" for patients with a calculocancer. Success was defined clinically by jaundice regression and biologically by decrease in bilirubinemia. Statistical analysis was performed by SPSS 20.0 software. In order to study the factors associated with the success of endoscopic biliary drainage,we used a binary logistic regression based on a varied and varied analysis. The factors studied were sex, age, the presence of metastases and endoscopic dilatation of the stenosis before prosthesis placement. ResultsThe mean age was 63 years +/- 10.3 with extremes ranging from 31 to 93 years and a sex ratio H / F of 1.3. The overall success was 76.2%. The comparative study of the success rate in the 3 groups showed a superiority of group B with a success rate of 84.3%, followed by group C with a success rate of 77.2%, then of group A with a success of 62.5%. In multivariate analysis, and by adjusting the studied parameters (age, sex, the presence of metastases and endoscopic dilatation of the stenosis before prosthesis placement), only the presence of metastases and the endoscopic dilatation of stenosis altered the success rate. Indeed, the presence of metastases increases the risk of failure (OR = 8.4, p = 0.001, 95% CI = [2.4-29.8]), and the endoscopic dilatation of the stenosis before placement. prosthesis significantly decreased the failure rate (OR = 0.05, p = 0.0001, CI (95%) = [0.013-0.19]). Conclusion: Our study confirms that the palliative treatment of neoplastic biliary stenosis by endoscopic drainage remains effective in case of pancreatic cancer, however the results are less satisfactory in cases of caclulocancer and cholangiocarcinoma. The presence of metastases appears to be significantly associated with failure of endoscopic biliary drainage, and endoscopic dilatation before prosthesis placement seems to be associated with its success. Further study with a larger sample is essential to verify these results.

In front of an increasingly aging population, the ERCP raises the question ofbenefit in the elderly. So we set ourselves the goal of comparing ERCP results in lithiasis pathology in elderly patients respectively less and more than 75 years old. Patients and Methods: This is a retrospective descriptive and analytical study conducted over a periodfrom May 2002 to February 2017, including 846 patients with ERCP for a lithiasic pathology. We divided our patients into two groups: thegroup I for patients younger than 75 years, and group II for patients over 75 years old. A patient was said to be aged from 75 years old. We realisedinitially a descriptive study of the characteristics of the elderly population, followed by a comparative analytical study of the results between the two groups concerning thesuccess rate and the rate of complications. Results:The group of elderly subjects (group II) accounted for 12.3% of the population (n = 101), with an average age of 80.17 +/- 5.43 years and extremes ranging from 75 to 96 years, sex H / F ratio was 1.2. Of these patients, 67.3% had no surgical history significant (n = 68), 28.7% were cholecystectomized, and only 4% antecedent of endoscopic biliary sphincterotomy. 5% of patients were admitted for acute pancreatitis (n = 5) and 25.7% were in acute cholangitis (n = 26). Radiologically, the average diameter of the VBP was 15.2 +/- 4.2mm. Choledochal stones were found in 37.8% of patients (n = 38), a large calculus was found in 10.9% of patients (n = 11). An SBE has been performed in 94.1% of patients (n = 95). The vacuity of VBP was obtained in 61.4% of cases in the patient group aged, compared to 78.4% in group I (p <0.001), use of laborers additional endoscopy was 30.7% in group II, compared to 18.3% only in group I (p = 0.003). The overall success rate was 85.2% in group II, compared with 92.5% in group I (p = 0.012). The rate of early complications was 6.9% in the group of elderly subjects, compared to 6% in group I, with no statistically significant difference (p = 0.48). Conclusion:Although the overall success rate remains better in the young patient , the results of ERCP in lithiasis pathology in the patients aged over 75 years remainsatisfactory, with no statistically significant difference in terms of complicationsearly ERCP. This allows us to deduce that the ERCP keeps all its interestin the elderly subject. A follow-up cohort study in the elderly still remainsnecessary to have more objective results.

We report a case of EUS guided puncture of the main pancreatic duct for difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) in a patient with recurrent acute pancreatitis (RAP).

A 72-years-old female referred to our Gastroenterology Unit for RAP. She had not known allergies and family history was not significant. She did not take medications, non-smoker, not consumed alcohol, and denied taking illicit drugs. She was previously submitted to laparoscopic cholecystectomy for symptomatic cholelithiasis (2010).

Two years after cholecystectomy, she experienced the first episode of acute pancreatitis (AP) presenting with epigastric pain, nausea, fever and elevation of amylase and lipase. Magnetic resonance cholangiopancreatography (MRCP) revealed a mild dilation of the extrahepatic bile ducts (7 mm) with narrowing of the distal common bile duct and mild Wirsung duct dilatation. She was submitted to endoscopic biliary sphincterotomy via ERCP and no stones were extracted, but was detected papillitis. It was ruled out hereditary cause of pancreatitis. The serological tests did not show a previous infection.

In the following months for the recurrence of AP she was underwent EUS that showed dilation of the common bile duct (10 mm) and a further MRCP which visualized a low insertion of the cystic duct into the choledochus. In an episode plastic metal stent placement in the common bile duct has been reported without success on the symptoms.

For the recurrent symptoms it was decided to opacify the Wirsung duct that had never been possible to cannulate due to technical difficulties also after secretin test. After several failed attempts to pancreatic catheterization at ERCP, it was decided to inject contrast by means of EUS to visualize periampullary pancreatic duct. After transduodenal puncture of the pancreatic duct using an EUS-fine needle (22-gauge), pancreatogram was performed and with duodenoscope has been obtained pancreatic catheterization with rapid drainage of the contrast. It was performed pancreatic sphincterotomy and a 5F plastic stent was placed, removed after a month. Until now the patient experienced a good relief of symptoms.

Conclusions

In this case EUS allowed to carry out a difficult access to the pancreatic duct during ERCP in a patient suffering from recurrent pancreatitis, probably secondary to an intermittent defect in the drainage of the Wirsung duct for fibrosis at the level of the papilla (stenosing papillitis).

Background: recurrence of non-metastatic GIST and need of adjuvant Imatinib are related to post-operative pathological evaluation. Pre-treatment risk factors are tumor diameter, mitotic rate and site (gastric vs non-gastric). EUS-guided tissue acquisition is the mainstay for diagnosis of GIST, unfortunately EUS-FNA does not reliably reflect GIST’s proliferation and size.

Aim: to investigate the EUS-FNB diagnostic yield for GIST and to evaluate whether EUS-FNB reflects prognostic criteria obtained from resected GISTs.

Methods: a prospectively maintained database was retrospectively reviewed to identify consecutive patients with surgically resected subepithelial lesions who received a diagnosis of GIST at a previous EUS-FNB with a 19 or 22G core-needle (EchoTip^®ProCore™, Cook Medical). Size from EUS examinaton and mitotic/proliferative indexes obtained from EUS-FNB samples were compared with surgical specimens.

Results: 18 patients were enrolled (11 males; mean age 71.6 years, range 44–88 yo). Tumour site was the stomach in 15/18 and duodenum in 3/18 patients. Agreement between EUS-FNB and surgical pathology was 100% with respect to the diagnosis of GIST (18/18). Proliferative indexes (Ki67/MIB1) were ratable in 14/18 (77.7%) of biopsies versus all cases of resected specimens and they were generally understimated. In 2/18 patients mitotic count was feasible (HPF>50) showing a mitotic index <5/50 HPFs confirmed by surgical specimens. In 16/18 patients no mitotic figures were observed in core biopsy specimen (1-22 HPF) whereas surgical specimens allowed to observe mitoses from 1 to 5 per 50HPF. Tumour size of the surgical specimen differed (>5 mm) EUS estimation in 12/18 subjects (66.6%) whereas it was comparable (± 5 mm) in 6/18 cases (33.3%). 

Conclusions: EUS-FNB have an extremely high diagnostic accuracy for GIST, however it underestimates proliferation indexes and rarely allows a reliable mitotic count mainly due to uneven distribution of the mitotic figures throughout the lesion. Furthermore, EUS generally underestimates the size of the lesions; this limit is linked to the “bidimensional” evaluation of lesions obtained by ultrasound. Our data obtained with EUS-FNB are similar to previous studies with FNA and constitute a major limitation for developing a possible pre-treatment and biopsy-based risk classification of GIST. Alternative parameters (genotype profiling) must be validated on pre-surgical biopsy samples from GISTs for prognostic purposes.