Introduction:

Endoscopic Ultrasound (EUS) is well-established mode of intervention for tissue acquisition in solid organs with rapid on-site evaluation (ROSE). In the Covid-19 era implementation of infection control mechanisms has led modified hybrid technique to get high diagnostic yield for tissue sampling. Combination of Covid-19 SOPs and tissue acquisition method outline this hybrid technique to get high diagnostic Yield. We share our initial experience of EUS cases performed with this approach without ROSE.

Methods:        

All 125 cases who underwent EUS guided biopsy from June 2020 till June 2022 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during procedure.

Results: Among these cases, 85 were male, mean age 56 years (range 22-90), Mean duration of procedure 28 minutes mean (10-90 min). 91 cases  for organ targeted for malignant pathology include pancreas 53, liver 03, lymph nodes 22, subepithelial lesions 10, mediastinal lesions 15, common-bile duct/gall bladder 07, gastric and retroperitoneal 01 case, 13 cases had a multi-targeted biopsy for the additional staging of disease. The number of ‘passes’ with the needle was average 02 with single pass 20, two pass 60, three passes 20, multitarget single pass in 25. Needle size (Franseen design) used for procedures was 22G in 115 cases and 25G in 10. Common tissue diagnoses include pancreatic adenocarcinoma 38, neuroendocrine tumours 06, tuberculosis 07, gastrointestinal stromal tumours 03, leiomyoma 05, lymphoma 06, metastatic renal cell carcinoma 05, squamous cell carcinoma 05, cholangiocarcinoma/gall bladder adenocarcinoma 13, Sarcoma 03 , solid pseudopapillary epithelial neoplasm of pancreas (SPEN) 03 and one case for Schwannoma, breast metastasis, accessory spleen, ectopic pancreas, sarcoidosis There were no immediate or early complications in all cases.

Conclusion:

Hybrid EUS in Covid 19 Era has emerged as a useful/cost-effective and safe approach to get tissue yield without the need for ROSE.

 Pseudocysts accompanying pancreatic solid lesions are rare findings and represent a big hurdle in obtaining a pre-operative histological diagnosis. Although they are usually complications of pancreatitis, pseudocysts can develop as a consequence of compression on the main pancreatic duct of solid masses whose characterization is essential. If the cyst is of moderate-large size, the acoustic effect of the fluid content and also the compression of the cyst itself on the pancreatic parenchima make often impossible to visualize the lesion which is squeezed too far from the probe to be seen. As a result, perfoming endoscopic-ultrasound guided fine needle aspiration/biopsy (EUS-FNA/B) of the solid mass underneath it is usually very challenging.

Description of the technique

When there is a suspicion of a solid mass along with a moderate-large size pseudocyst, having a histological confirmation of cancer before surgery is essential and nowadays considered as standard of care. Using a 19G FNA needle to aspirate the cyst to dryness improves dramatically the lesion accessibility which becomes in the end visible and approachable with a standard EUS guided FNA or FNB. The procedure is safe and easy to perform under conscious sedation.

Conclusions

EUS guided aspiration of large pseudocysts developed as complication of pancreatic lesions can be a crucial step in facilitating the histological confirmation of potential malignant lesions prior to surgery, allowing their visualization and biopsy.

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 histology (SRH) imaging based framework that demonstrates gastro-intestinal (GI) and brain (CNS) cancer detection of unprocessed human surgical specimens. The technique can observe in real time a fresh biopsy sample and generate a virtual histology image, in 3D, that show excellent agreement with the standard hematoxylin, eosin (HE) staining. The attached figure shows an overlay of an SRH image (acquired in 1s) on an ex-tempo HE image obtained in 40 minutes in an intra-operative context. We report excellent agreements between SRH and HE images acquire on the same patients for healthy, pre-cancerous and cancerous colon, pancreas and liver biopsies. Finally, we show that the SRH imaged samples remain fully compatible for further histological work such as histo-chemistry and molecular biology. This proves to be a valuable asset when the biopsy is small and valuable as in brain stereotaxic samples. These developments pave the way for instantaneous label free GI and CNS histology in an intra-operative context.

BACKGROUND: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is a maim technique for diagnosis of pancreatic and non-pancreatic tumors. The 20G ProCore FNB needle, plays an important role in obtaining better samples for accurate diagnosis, as it enables histopathological study of the specimens. 

AIMS:  demonstrate the experience in endoscopic ultrasound guided biopsy for the study of pancreatic and non-pancreatic solid tumors using the 20G ProCore needle,

METHODS: We conducted a retrospective study of 18 years older patients with pancreatic and non pancreatic solid tumors who underwent EUS guided FNB using a 20G ProCore needle from January 2019 to November 2021 in a Colombian referral universitary hospital of biliopancreatic diseases from Bogota Colombia. We investigated the patients’ clinical characteristics and the diagnostic accuracy and safety. The primary outcome was the accuracy and secondary outcomes were technical factors and related complications. 

RESULTS: A total of 29 patients were included, average age of 65 years. Gender distribution: 51,7% were female gender and 48,27% were male. Pancreatic tumors (79,3%) and non-pancreatic tumor (20,68%), tumor size between 10 to 61 mm (median 34 mm). Pancreatic tumors were located mainly at the head (52,1%), body (34,78%) and tail (8,69%), Regarded to non-pancreatic tumors, distribution was peripancreatic in 4,34% and mediastinum, perigastric and hepatic hilum. Diagnostic accuracy was 93,10%. 66% was malignant tumors being adenocarcinoma de most common finding in 44,4% of the cases, followed by poorly differentiated carcinoma and neuroendocrine tumors (33%). Related complications, present in 1% of the cases.

CONCLUSIONS: Endoscopic ultrasound guided FNB using  20G ProCore needle has a high diagnosis accuracy for pancreatic and non-pancreatic tumor, independent of the location and size of the tumor,  with low adverse events. Our study demonstrated similar technical successes, and diagnosis accuracy in the diagnosis of malignant solid tumors compared with other literature reports.

Malignant melanomas are insidious aggressive cancers that can prove to be fatal, with Australia harbouring the highest incidence of skin cancers worldwide. Surprisingly, as little as 13.4% of patients undergoing surgical resection of high-risk melanomas remain disease free after two years with 31.6% showing evidence of distant spread. Although rare, secondary tumours of the Ampulla of Vater have been documented with the most common primaries involving breast, renal and melanoma cancers. We report the case of a malignant melanoma of the Ampulla of Vater occurring in a patient 4 years post-surgical resection of a Stage II melanoma manifesting as acute pancreatitis with obstructive jaundice. Given the rarity of secondary ampullary tumours, metastatic melanoma should always be considered in patients with obstructive jaundice and a history of melanoma resection. In the absence of distant disease, surgery may be considered along with other forms of palliative therapy after consensus at MDT and consideration of patient preference. 

Introduction

 EUS-guided sampling is an effective diagnostic method in the etiological workup of biliopancreatic masses. We aimed to evaluate the performance of EUS-guided sampling in biliopancreatic masses. Purpose We aimed to evaluate the performance of EUS-guided sampling in biliopancreatic masses.

Materials and methods

 This was a retrospective study, over 26 months, that was included all patients with a biliopancreatic mass who had undergone a EUS guided sampling, either by fine-needle aspiration (FNA) or by fine-needle biopsy (FNB). The EUS was performed under sedation, using FNA needles (22G and 19G) or FNB needles (22G and 20G). During the sampling process, the slow pull capillary technique with macroscopic on-site evaluation (MOSE) was applied.

 Results

 Forty-five EUS guided sampling were carried out. The median age of patients was 63 years [36–85] with a sex ratio M/F of 1.36. The sampling site was pancreatic in 39 cases (86.66%), ampullary in 6 cases (13.33%). The needle’s trajectory was transduodenal in 44 cases (97.8%) and transgastric in one case (2.2%) for a pancreatic tail mass. The average number of needle passes was 2. The result was conclusive in 73.3% of cases and inconclusive in 26.7% of cases. FNB was used in 30 cases (66.7%) with 21 samples (70%) being conclusive, and FNA was utilized in 15 cases (33.3%) with 11 FNA (73.33%) being conclusive. Pancreatic adenocarcinoma was found in 64.4% of cases (n = 29), biliary adenocarcinoma in 6.7% of cases, three cases had borderline normal pancreatic tissue. The diagnostic accuracy, sensitivity, and specificity of all EUS guided sampling were respectively 73%, 72%, and 100%. Six patients (13.3%) were found to be free of neoplastic cells, and four (8.9%) had hemorrhagic and inflammatory specimens. No complications related to the procedure were observed.

 Conclusions

 EUS guided sampling combined with the slow pull capillary technique and MOSE allows a diagnostic accuracy of more than 73%. Patients with indecisive results would require a second diagnostic method (second EUS guided sampling, percutaneous ultrasound/scanno-guided biopsy, or surgical biopsy) after discussion in a multidisciplinary team.

Introduction

Cystic pancreatic neoplasms are characterized by the replacement of the pancreatic epithelium to neoplastic mucussecreting cells. The diagnostic approach aims to confirm the diagnosis of a cystic tumor and evaluates its benignity or malignancy. Purpose We aimed to evaluate the performance of EUS guided sampling of cystic pancreatic neoplasms.

Materials and methods

This was a retrospective study, over 24 months, that was included all patients with cystic pancreatic neoplasms who had undergone a EUS guided fine-needle aspiration. The EUS was performed using fine-needle aspiration (FNA) needles (22G and 19G)or fine-needle biopsy (FNB)needles (22G). During the sampling process, the macroscopic aspect of the liquid was noted and in the presence of associated solid mass, the slow pull capillary technique with macroscopic on-site evaluation (MOSE)was applied.

Results

patients benefited from a EUS-guided aspiration of suspicious cystic pancreatic neoplasms. The median age was 58.5years[38-84] with a sex ratio M/F of1.25. FNA or FNB was done for all patients. The median size of cysts was 26.72mm[16-70mm]. The number of passages required was 2passages for 9patients (90%) and 1passage for 1patient (10%). The needle used was a 22G needle for 7patients (70%), a 22G-Procore for 2patients (20%), a 19G needle for 1patient (10%). A EUS guided sampling of solid mass associated was performed in 8patients (80%). The communication between the cyst and branch duct was found in 5patients (50%), a cystic mass appearance was found in 5patients (50%). The appearance of the liquid was clear in 6patients (60 %), sero-haematic in 3patients (30%) brownish and viscous in 1patient (10%) Mural nodules were absent in 8patients (80%), present in 2patients (20%) The biochemical analysis of the cystic liquid was done for CEA and amylase in 4patients (40%) and were 291.38[2.55-1040] and 20538.6[5-83330] respectively. The seric CA19-9 and CEA were 159.41[2-1164] and 6.6[1.09-5.6] respectively. The histopathological analysis found adenocarcinoma in 3patients (30%), hemorrhagic and inflammatory in 2patients (20%), a ductal mutinous tumor in 1patient (10%), a serous cyst in 1patient (10%), and lymphocytic infiltrations in 1patient (10%).

Conclusions

EUS guided sampling of cystic pancreatic neoplasms was conclusive in (50%)of patients and allowed histological proof of malignancy. A negative result can be handled by a second attempt.

Introduction : L’écho-endoscopie (EE) a fait ses preuves dans la caractérisation des lésions  gastriques sous muqueuses (LGSM). D’introduction relativement récente dans notre centre, nous nous proposons à travers ce travail, de rapporter notre expérience et d’évaluer la concordance de l’EE avec le diagnostic radiologique et histologique des LGSM.  

Méthodes :

Type d’étude : Il s’agit d’une étude rétrospective, monocentrique, descriptive

Période : 3 ans (Janvier 2019- Juin 2022)

Inclusion : Nous avons inclus tous les patients présentant une LGSM chez qui une écho-endoscopie a été pratiquée afin de caractériser la lésion.

Modalités de l’EE: L’examen était réalisé sous anesthésie générale, moyennant un échoendoscope de type Fujifilm^® radial ou linéaire.

Paramètres étudiés : Nous avons recueilli les données cliniques, endoscopiques, morphologiques histologiques, si disponibles et thérapeutiques et calculé la concordance de l’EE avec l’imagerie et l’histologie.

Résultats :

Trente-trois LGSM ont été colligées (chez des patients d’âge moyen de 52 ans [21 – 69 ans] et de genre-ratio H/F de 0,3). En endoscopie, les lésions avaient une taille moyenne de 18 mm ­[3-49], d’aspect ulcéré dans 14 des cas, de muqueuse d’aspect normale (n=10), polyploïde (n=4), ombiliqué (n=3). 

En EE, les LGSM se développaient à partir de la 4^ème couche dans 52% des cas, de la 3^ème  couche dans 26% des cas, et de la 2^ème  couche dans 13 % des cas.

Les lésions étaient homogènes chez 8 patients et hétérogènes chez 15 autres ; associées à des adénopathies chez 8 patients.

Au terme de l’EE, parmi les LGSM,  les diagnostics évoqués étaient : Tumeur stromale (n=9), tumeur neuroendocrine (n=1), lipome (n=2), pancréas aberrant (n=2), ADK gastrique (n=1),lésion d’allure kystique (n=1), léiomyome (n=1). Vingt (66%) patients ont eu une confirmation histologique. Sur le plan anatomopathologique, les diagnostics retenus étaient une tumeur stromale gastrique (n=6), tumeur neuroendocrine (n=2), adénocarcinome gastrique (n=3), lipome (n=1) et léiomyome (n=1).

Finalement, les résultats écho-endoscopiques étaient concordants avec l’imagerie chez 17 patients (51%) et chez 13 patients parmi les 20 (65%) ayant eu une confirmation histologique.

Conclusion : Les résultats de notre étude confirment l’intérêt de l’écho-endoscopie dans la caractérisation des lésions sous muqueuses gastriques permettant un diagnostic présomptif dans plus de la moitié des cas et en orientant ainsi la prise en charge de ces lésions.

Introduction

Spleen can be the site of infectious as well as malignant lesions. With Cross-Sectional imaging these lesions can be localized but histology is essential for definitive diagnosis. Strategies to obtain splenic mass tissue include surgical, and percutaneous image guided approaches. Endoscopic Ultrasound (EUS)-guided biopsy is a safe and effective method for obtaining samples from spleen as an alternative to splenectomy.

Methods

We present two cases of splenic lesion underwent EUS guided biopsy. Procedure was done after informed consent with standard coagulation profile/ platelet counts and performed under conscious sedation. No immediate or late complications or adverse events noted.

Results

Case 1;

72 years old male known case of vasculitis on multiple immunosuppressant medications came with complaints of abdominal pain and weight loss. CT scan abdomen revealed splenic mass and EUS-guided splenic mass biopsy was performed which revealed B cell related lymphoproliferative disorder.

Case 2:

62 years old female presented with weight loss and decrease appetite, CT scan showed large splenic mass with another peripancreatic nodal mass. EUS guided biopsy performed revealed diffuse large B cell Lymphoma.

Conclusion

EUS-S in patients with splenic masses is a safe and effective diagnostic modality as an alternative to splenectomy.

Lymphangiomas are rare, benign lesions of vascular origin with lymphatic differentiation. Pancreatic lymphangiomas are extremely rare (less than 0.2% of all pancreatic lesions).

We present the case of a 44-year-old male who underwent a CT scan that showed an hypodense nodular image located between the inferior vena cava (IVC) and the 2nd part of the duodenum. An endoscopic ultrasound showed a cystic lesion with a well-defined and regular wall and a long axis of 23 mm located between the IVC and the cephalic portion of the pancreas and in proximity with the hepatic hilum, raising the hypothesis of a pancreatic cystic lesion. However, fine needle aspiration (FNA) revealed a milky fluid, raising the likely possibility of a lymphangioma. The fluid triglyceride was elevated and citology showed a predominance of lymphocytes, supporting the diagnosis of lymphangioma. Pancreatic lymphangioma is often asymptomatic and discovered as an incidental finding but the clinical presentation depends on the size, location, mass effect and complications. Most of the imaging studies are non-specific and cannot reliably distinguish between a lymphangioma and a pancreatic neoplasm. However, EUS can allow a preoperative diagnosis, particularly because of EUS-FNA of the cystic fluid and its  consequent citological and biochemical studies. In asymptomatic patients, a conservative approach with imaging surveillance can be undertaken. However, curative treatment involves complete surgical excision.

Background

Primary pancreatic lymphoma (PPL) is a rare disease with clinical and radiological features often resembling pancreatic adenocarcinoma which is the most common primary pancreatic malignancy. Since both malignancies have different clinical outcomes with the former having a good prognosis, it is therefore important to have histopathological and cytopathological diagnosis of suspected pancreatic lesions. We present a case encountered as obstructive jaundice as our experience.

Case Presentation

We report a case of a 60-years-old woman known case of ischemic heart disease presenting with abdominal pain and jaundice of one month duration.  Patient for referred with abdominal imaging  CT scan Abdomen; findings  suggestive of pancreatic head mass. Subsequent Endoscopic ultrasound EUS guided biopsy was done using 22G FNB needle with tissue cores were obtained. Final histology confirmed it to be a primary pancreatic lymphoma with immunohistochemical stains suggestive of B cell origin lympho-proliferative disease. Patient also develop gastric outlet symptoms and underwent percutaneous biliary drainage as ampulla not accessible endoscopically to jaundice. PET scan was done for staging of disease before starting chemotherapy. She was started on R-CHOP (Rituximab, cyclophosphamide, Doxorubicin Hydrocholoride,Vincristine Sulphate,Prednisone) chemotherapy and completed 6 cycles. Her end of treatment follow up  PET-CT scan showed interval  normalization of FDG avid mass.

Conclusion

Keeping In view the excellent response to treatment in case of PPL, this rare entity which is often mistaken as a pancreatic adenocarcinoma should be kept in the differentials of any pancreatic lesions and EUS guided biopsy should be consider in suspected cases for early diagnosis and prompt treatment.

Introduction:

Endoscopic Ultrasound (EUS) has emerged as a useful tool to obtain tissue acquisition for diagnosis. In mediastinology, EUS plays its supportive role in certain areas in mediastinum to obtain via trans-oesophageal route safely and accurately tissue diagnosis from lesions suspected likely malignancy either lung pathologies or metastasis from other primaries. In third world countries tuberculosis is also commonly encountered along with it. We share our initial experience of different pathologies encountered in EUS guided biopsy of mediastinal lesions.

Methods:

Total of 21 cases underwent EUS guided Biopsy from June 2020 till June 2022. Informed consent was obtained, with Covid screen test with PCR was performed before procedure.  Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle in 20 cases and 25G in one case; Franseen design with capillary suction method used to obtain visible core samples for histopathology without Rapid-Onsite-Evaluation (ROSE). All cases have adequate sample for histological diagnosis. Post procedure oral antibiotic was given to all patients.

Results:

Among these cases, 13 were male, mean age 55 years (range 22-87), mean duration of procedure 21 minutes (10-35 min). Majority of them; 12 cases were malignant pathologies while remaining 09 were benign. The number of ‘passes’ with the needle was average 2.5 with single pass 02, two pass 10, three passes 05 and multitarget lesions were 04. There were Mediastinal lesions in 16 cases and mediastinal nodes biopsy in 05 cases. Common tissue diagnoses include Tuberculosis 06, Squamous cell Carcinoma 04, Lymphoma 03, Benign in 02, Sarcomatoid carcinoma 02 and Metastatic renal Cell Carcinoma 01, Metastatic breast 01, Sarcoidosis 01, Solitary fibrous tumour 01. There were no immediate or early complications in all cases.

Conclusion:

EUS guided biopsy of lesions in different mediastinal areas is safe and provide tissue diagnosis with high diagnostic accuracy with use of FNB needles.

Introduction: With the advancement in endoscopic technology, Endoscopic Ultrasound EUS guided approach in diagnosing and surveillance of subepithelial lesions is crucial in management of these rare lesions identified incidentally on routine endoscopy. EUS plays crucial role in providing tissue diagnosis also to identify its origin which layer it arise and in addition its behaviour whether benign or malignant. We share our experience of different spectrum of cases of SELs we encountered during routine endoscopy.

Methods: All 10 cases who underwent EUS guided biopsy from June 2020 till June 2022 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during procedure. Procedures were done in conscious sedation and informed consent was obtained. All sample were collected using MOSE macroscopic onsite evaluation.

Results: Among these cases, 05 were male, mean age 52 years (range 35-73), Mean duration of procedure 22 minutes mean (13-35 min). 08 cases have malignant/premalignant pathologies while remaining 02 cases were benign. Majority of lesions had gastric origin 08 while remaining 02 were oesophageal. The number of ‘passes’ with the needle was average 2.4 with two pass 05, three passes 04 while one patient had obvious diagnosis no biopsy was done. Needle (Franseen design) used for procedures was 22G size in all 09 cases. Common tissue diagnoses include gastrointestinal stromal tumours 03, Benign (Ectopic pancreas) 02, leiomyoma 04, and Schwannoma 01. There were no immediate or early complications in all cases.

Conclusion: EUS plays a crucial role in evaluation of subepithelial lesions SELs; to confirm its diagnosis as well its origin which layer it arise, make a management plan and its surveillance when required in smaller lesions.

Introduction

Neuroendocrine tumors (NET) are rare, with gastrointestinal tract and lungs being the most frequent sites of origin. These tumors are most often diagnosed by endoscopists and frequently as incidentally found lesions. Endoscopic ultrasound (EUS) is a good modality to evaluate these lesions.

Method

We present six cases diagnosed as NETs on histopathology with different spectrum of presentation, endoscopic features and site of origin. Endoscopic and EUS guided biopsy was performed to help evaluate and stage these lesions in all cases.

Results

Case-1: 47 years old female, underwent EUS guided biopsy for a large well defined homogenous-hyperechoic mass in the head of pancreas. Case-2: 35 years-old male patient, underwent EUS guided biopsy performed for a large > 5 cm solid-cum-cystic lesion noted in the head/uncinate process of pancreas. Case-3: 51 years old female, presented with bleeding PR and weight loss. Colonoscopy demonstrated a semi-circumferential ulcerated friable fungating mass starting from anal verge upto 10 cm. Case-4: 61 years old female, with left breast Invasive ductal carcinoma. Staging CT scan showed porta-hepatis mass. EUS shows well-defined nodal vascular mass at the porta hepatis and peri-gastric region.Case-5: 60 years old female, underwent upper GI endoscopy (OGD) for dyspepsia, which showed incidental finding of sub-epithelial nodule in D1. EUS demonstrated a well-defined tumor within layer 4 of anterior wall of duodenal bulb with intact serosa. Case-6: 41 years old female underwent OGD for abdominal symptoms and anemia, which revealed a polypoidal mass in gastric body. EMR was used to resect the lesion.

Conclusion:

NET`s can be found at various sites in the GI tract, and EUS with biopsy are extremely helpful in the diagnosis and staging of disease.

Introduction: Endoscopic Ultrasound EUS is now considered as standard of care in diagnosis of oncology patient to help plan management. Endoscopy in elderly population is also important when they need tissue diagnosis to further treatment plan in suspected malignant pathology. We share our experience of EUS-G in elderly population which plays pivotal role in their management. All sample were considered adequate by expert pathologist to conclude histological diagnosis.

Methods: All 40 cases who underwent EUS guided biopsy from June 2020 till June 2022 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during procedure. Procedures were done in conscious sedation and consent was obtained and those patients who were on antiplatelet or anticoagulation agents were hold as appropriate. All sample were collected using MOSE macroscopic onsite evaluation.

Results: Among these cases, 32were male, mean age 73 years (range 65-90), Mean duration of procedure 27 minutes mean (10-71 min). 32 cases for organ targeted for malignant pathology include pancreas 17, lymph nodes 03, subepithelial lesions 01, mediastinal lesions 08, common-bile duct/gall bladder 05, and retroperitoneal 01 case, 05 cases had a multi-targeted biopsy for the additional staging of disease. The number of ‘passes’ with the needle was average 2.4 with single pass 07, two pass 18, three passes 07, multitarget single pass in 08. Needle size (Franseen design) used for procedures was 22G in 35 cases and 25G in 05. Common tissue diagnoses include pancreatic adenocarcinoma 15, tuberculosis 01, gastrointestinal stromal tumours 01, Benign 07, lymphoma 01, metastatic renal cell carcinoma 04, squamous cell carcinoma 03, cholangiocarcinoma/gall bladder adenocarcinoma 05, and Sarcoma 03. There were no immediate or early complications in all cases.

Conclusion:

EUS-G is safe and effective modality in evaluating and diagnosing different variety of pathologies in elderly populations with high diagnostic yield.

Introduction: In case of bleeding after gastric endoscopic submucosal dissection (ESD), it is difficult to decide whether to perform emergent hemostasis or not. This study was designed to clarify differentiating factors for significant gastric post-ESD bleeding which requires emergent hemostasis.

Methods: A total of 2,039 cases who developed bleeding after ESD for gastric neoplasm in a single center were enrolled. Their medical records were retrospectively reviewed. Their comorbidities, biochemical results, pathologic characteristics, history of previous ESD, current medication, and clinical findings at the time of bleeding events were reviewed. Significant bleeding was defined as bleeding which required emergent embolization or endoscopic hemostasis for visible exposed vessels or ongoing bleeding.

Results: Out of the total 2,039 ESD patients, 309 developed post-ESD bleeding. Among them 113 (36.6%) underwent an endoscopy and 73 (23.6%) needed embolization or endoscopic hemostasis. In those who did not undergo an endoscopy, the bleeding was minor and spontaneously improved. Overall, factors independently related with significant bleeding were demonstrated as hypoalbuminemia (OR 19.743, 95% CI: 2.084-187.011, p = 0.003), size of the specimen (OR 1.252, 95% CI: 1.025-1.528, p = 0.027), and previous history of adjacent ESD (OR 6517, 95% CI: 1.593-26.669, p = 0.009). Whereas, location of the lesion, malignant pathology of the lesion, and shock at the time of bleeding event were not associated with significant bleeding.

Conclusion: For post-ESD bleeding in patients with hypoalbuminemia, large size of specimen, or previous history of adjacent ESD, emergent hemostasis should be considered.