Conventional histopathology, currently the ‘gold-standard’ for pathological diagnosis of cancer, requires extensive sample preparations that are achieved within time scales that are not compatible with intra-operative situations where quick decisions must be taken. Providing to pathologists a close to real-time technology revealing tissue structures at the cellular level with histologic quality would provide an invaluable tool for surgery guidance with evident clinical benefit. Here, we specifically develop a stimulated Raman imaging based framework that demonstrates gastro-intestinal (GI) cancer detection of unprocessed human surgical specimens. The generated stimulated Raman histology (SRH) images combine chemical and collagen information to mimic haematoxylin, eosin and saffron (HES) staining. The attached figure shows an example of SRH image obtained in 50 minutes as compared to the standart HES image obtained in 24h. We report excellent agreements between SRH and HES images acquire on the same patients for healthy, pre-cancerous and cancerous colon and pancreas tissue sections. We also develop a novel fast SRH imaging modality that captures at the pixel level all the information necessary to provide instantaneous SRH images. These developments pave the way for instantaneous label free GI histology in an intra-operative context.

Figure label: SRH (a) and HES (b) images of healthy colon over a 0.8 mm x 1 mm. Zooms SRH (c) and HES (d). Scale bares 100µm.

Background EUS-guided drainage is suggested as the first approach in the management of symptomatic WON. A step-up method, including percutaneous drainage and mini-invasive surgery, is also proposed in case of either refractory or complex collections. Recently, a new LAMS with an integrated electrocautery delivery system (EC-LAMS) have been developed, facilitating drainage with its large lumen and wide flares. Although a single transluminal access is preferred, multiple step-up gateway technique is also proposed in case of multiple, large or low-responding WON.

Methods This is a retrospective analysis of prospective collected data of 5 consecutive patients (pts) with symptomatic complex WON, defined as large (>12 mm), septated or multiple, symptomatic collections, drained with a single-step, multiple gateway technique using EC-LAMS. Patients demographic, technical and clinical success, procedure time, necrosectomy sessions, further treatment needed, adverse events and post-procedure hospitalization were recorded and statistically analyzed.

Results Pancreatitis had biliary, alcoholic, post-traumatic, post-ERCP and idiopathic etiology. WON were located in the head-body of the pancreas (2/5 pts), in the body-tail (1/5 pts) and beside the whole pancreas (1/5 pts). WON were single with septa in 3 pts, multiple in 2 pts. 10 EC-LAMS were deployed with both transgastric and transduodenal approach (Table 1). Technical success was 100%. Procedure mean time for the deployment of two EC-LAMS was 29 min. Necrosectomy was completed in up to 3 sessions, if debris were still present, achieving clinical success in  3 cases (80%), with no recurrence in all the patients. One patient required a concomitant percutaneous drainage to yield healing and one required surgical necrosectomy. We reported one moderate bleeding, on the 1^st post-operative day (POD), treated endoscopically and one severe bleeding, on 10^th POD, requiring embolization. Both these adverse events seemed to be related to the endoscopic necrosectomy.

Conclusion Patients affected by multiple, septated, large WON can be considered “hard-to-treat-patients” and a single gateway could represent an insufficient treatment. Our case series showed that a single step multiple gateway technique using EC-LAMS is safe and feasible reducing number of endoscopic procedures and hospital stay. However further prospective, randomized, controlled studies are needed to define the long-term outcomes of this approach in complex WON.

Introduction: Pseudocyst pseudocysts are defined according to the Atlanta Consensus Conferenceas collections of pancreatic fluid surrounded by a tissue wallfibrous granules devoid of epithelium. Therapeutic options availablecurrently are surgical treatment, radiological drainage, and treatmentEndoscopic. The objective of our study is to evaluate the therapeutic results ofEndoscopic guided cystogastrostomy in the treatment of pseudocystspancreas and compare them with data from the literature. Materials and methods:This is a retrospective and descriptive study of patientswith symptomatic and persistent pancreatic pseudocysts after asix weeks. All these patients had benefited from a cystogastrostomyguided by endoscopic ultrasound using a linear echoendoscope and a cystotome. Aor several prostheses were then set up depending on the size of the collection andits content. Results: 23 patients underwent EUS-guided cystogastrostomy. Thesex ratio H / F was 1.5. Pseudocysts complicated acute pancreatitis in20 patients, pancreatic surgery in one patient and was post traumatic ina patient. The average age of the patients was 52.69 +/- 12.85 years. The average size ofpancreatic collections was 11.95 +/- 3.24cm. The technical success rate was95.65%. The complication rate was 4.5%. During an average follow-up of8.7 +/- 5.26 months, the therapeutic success rate was 90.9%. Two patients havepresented a clinical recurrence due to superinfection, and were bothtreated by surgery. The overall mortality rate was 4.35%. Conclusion: The results of our study confirm the efficacy and safety ofendoscopic guided cystograstrostomy in the first-line treatment ofpancreatic pseusocysts, and therefore invite us to use it whenever themeans permit.

Introduction: EUS-FNA in the diagnosis of solid pancreatic tumors showed a high accuracy (from 79 to 92%). However, differential diagnosis between pseudotumoral masses and pancreatic neoplasms can be challenging in the setting of chronic pancreatitis (CP) and the reported EUS-FNA sensitivity for malignancy in parenchymal masses of patients with concurrent CP was inferior (from 59 to 73%). Aim and Methods: To evaluate the diagnostic accuracy of EUS-FNB in differentiating between inflammatory masses and malignancies in CP. We performed a retrospective analysis of prospectively maintained, multicentric, database. The study evaluated consecutive subjects undergoing EUS-FNB for pancreatic masses presenting clinical, radiological or endosonographic features of CP in accordance with Rosemont criteria. All procedures were performed using 20, 22 or 25 G core-needles (EchoTip^®ProCore™). Final diagnoses were obtained from surgery or after at least 6 months of clinical and radiological follow-up. Results: 100 patients (59% males, mean age 62.4 yo + 9.4) met the inclusion criteria. Pancreatic lesions were located at: head (32%), neck (26%), tail (22%) and body (20%). EUS-FNB was performed by using a 20, 22 or 25-G needle in 5%, 38% and 57% respectively. An adequate histology sample was obtained in all cases. 53 lesions (53%) were finally considered as malignant and 47% as benign. Overall, a correct diagnosis was obtained in all but 7 cases [diagnostic accuracy 93% (95%IC 86.1%-97.1%), sensitivity 86.8% (95%IC 74.6%-94.5%), specificity 100% (95%CI 92.5%-100%), PPV 100%, NPV 87% (95%CI 77.1%-93.1%)]. We found that the 20-G needle had a diagnostic accuracy of 80% (95%CI 28.4%-99.5%); the 22-G needle showed a diagnostic accuracy of 92.1% (95%IC 78.6%-98.3%); the 25-G needle presented a diagnostic accuracy of 94.7% (95%IC 85.4%-98.9%). At binary logistic regression, only focal pancreatitis (OR 4.9; p<0.001), higher Ca19-9 (OR 2.3; p=0.02) and tail location of mass (OR 0.2; p<0.001) were independent factors associated with correct diagnosis. Gender, age, Rosemont criteria, mass size, number of passes and features at contrast harmonic EUS (CH-EUS) were not predictive of correct diagnosis. Conclusion: EUS-FNB is effective in the differential diagnosis between pseudotumoral masses and solid neoplasms in CP, showing a high diagnostic accuracy (93%). EUS-FNB should be considered the preferred diagnostic technique for diagnosing pancreatic cancer in the setting of CP.

Introduction: The hydatid cyst of the liver (KHF) is a parasitic disease due to the development ofthe larval form of the taenia of the dog Echinococcus granulosus. By its clinical latency, theDiagnosis is most often at the stage of complications. Fistulization of the cysthydatid in the bile ducts is the most common complication.endoscopy is necessary because of the therapeutic problems and risks associated withsurgery. The objective of our study was to evaluate and analyze the effectiveness of ERCPin the diagnosis and treatment of hydatid cysts of the liver broken in the pathways ducts. Materials and methods: This is a 15-year retrospective and descriptive study, ranging from January 2002 toOctober 2017, focused on patients with fistulized KHF in the pathwaysBile. ERCP and endoscopic biliary sphincterotomy were performed in allpatients, 18 times preoperatively and 21 times postoperatively. Results: 39 patients with ruptured KHF in the biliary tract, 2.4% of the indicationsERCP in our series were included. The average age of patients was 47,with male predominance in 65% of cases. KHF broken in the waysgalls were complicated by persistent external biliary fistula postoperativelyin 34% of cases. Sphincterotomy was performed in all patients allowingremoval of hydatid material by extraction balloon or Dormia basket.The evolution was marked by the disappearance of jaundice after 5 to 12 days inaverage after endoscopic gesture and dryness of external biliary fistulaafter 10 to 12 days. Conclusion: The results of our study confirm the efficacy and safety of ERCP and theendoscopic sphincterotomy in biliary complications of echinococcosishepatic. It makes it possible to shorten the post-operative stay and to avoid areoperation, often difficult and haemorrhagic.