Background: Pancreatic mass sampling has historically been performed by endoscopic ultrasoundguided fine needle aspiration (EUS-FNA). However, its sensitivity has been reported to be within a wide range, which limits its reliability. Fine needle biopsy (FNB) has been shown to have superior diagnostic performance and is increasingly replacing fine needle aspiration. In FNA, 25 gauge (G) needles appear to outperform 22G. Data comparing these sizes in FNB platforms is limited. We aimed to prospectively compare the performance of 22G and 25G Franseen-tip core biopsy needles in the sampling of solid pancreatic lesions. Patients and Methods: Patients who underwent EUS-FNB of pancreatic lesions at the Indiana University Hospital using 2 needle sizes: 25G (Study group) and 22G (Control group) using the Acquire needle (Boston Scientific Co., Natick, MA, USA) were enrolled. Needle choice was left to the discretion of the endosonographer. Tissue specimens were evaluated onsite, and underwent touch and smear and cellblock preparation. Specimens were independently evaluated by 2 expert cytopathologists blinded to diagnosis. Cytopathologists assessed cytological yield (on smears) and histological yield (on cellblock) using a validated scoring system reached by a consensus among our cytopathologists as we have previously published. Results: A total of 75 patients (42 males, median=65 years) underwent EUS-FNB during the study period (2017)(2018): 50 using 25G and 25 using 22G needle. Diagnostic yield was numerically higher in 25G (98% vs. 88%, p=0.105). Number of passes for smears were similar, however the 25G group required additional passes for cell-block (1.6 vs. 0.4, p=0.001). 25G was used more frequently for pancreatic head and uncinate process sampling (70% vs. 52%, p=0.126). Four patients had self-limited adverse events in the 22G group, but none in the 25G group. Conclusion: We report no difference in the diagnostic yield between 25G FNB vs. 22G sampling device with Franseen style tip, however, the 25G needle use was associated with the need of additional passes to collect a sufficient cell block.Endoscopic-ultrasound (EUS)-guided tissue acquisition of pancreatic lesions has primarily been conducted by fine needle aspiration (FNA). This method carries minimal risk of complications and has largely been successful; however, a major drawback is a wide reported range of sensitivity between 65%-92% (1, 2). This implies that the false-negative rate can be unpredictably high, and therefore a negative FNA may not rule-out pancreatic malignancy.Fine-needle biopsy (FNB) is rapidly gaining popularity for sampling of pancreatic lesions. FNB allows for better preservation of tissue structure and hence histological analysis. This is beneficial in difficult cases that include significant inflammation or fibrosis from chronic pancreatitis that can obscure the diagnosis of malignancy. FNB may also provide an adequate sample for immune-histochemical staining, which is necessary for confirming neuroendocrine tumors and for the diagnosis o...

Atlanto-occipital dislocation (AOD) is a craniocervical injury that has serious neurological consequences and is often fatal. High-speed blunt trauma, such as motor vehicle accidents, that extend and put traction on the head can cause this injury. The current recommendation for diagnosis is to measure the condyle-C1 interval (CCI) using a computed tomography (CT) scan in the coronal plane and more recently in the sagittal plane. We report the case of a patient who suffered a motor vehicle accident and had concomitant AOD and atlanto-axial dislocation. In this particular case, the CCI method failed to diagnose AOD and the diagnosis was made using the basion-dens interval (BDI) and other methodologies, as well as the presence of ligamentous disruption at the craniovertebral junction (CVJ) on magnetic resonance imaging (MRI).A 19-year-old female suffered a motor vehicle accident in which she was ejected from the car. Her neck was immobilized on the scene and she was brought to the emergency department complaining of neck pain. CT of the cervical spine showed concomitant atlanto-occipital and atlanto-axial dissociation. MRI of the cervical spine confirmed the diagnosis with total ligamentous disruption at the CVJ and distraction of the atlanto-axial joints bilaterally. While the CCI was normal, the BDI was diagnostic of AOD.The current recommendations for using the CCI interval method may not diagnose AOD in the presence of associated atlanto-axial dislocation. Other methodologies should be employed including BDI and basion-axial interval (BAI) as well as MR imaging showing ligamentous disruption.

INTRODUCTION: Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) is increasingly replacing fine needle aspiration (FNA) for sampling of solid pancreatic lesions. In FNA, 25G needles appear to outperform 22G needles in sampling pancreatic lesions, but data comparing 22G and 25G FNB platforms is lacking. We aimed to prospectively assess the performance of 22G and 25G Franseen tip core biopsy needles in the sampling of solid pancreatic lesions. METHODS: Consecutive patients were enrolled between 2017 and 2018 and underwent EUS-FNB sampling of solid pancreatic lesions at Indiana University Hospital using 2 needle sizes: 25G (Study group) and 22G (Control group) Acquire needles (Boston Scientific Co., Natick, MA, USA). The endosonographer chose the needle size based on lesion location and characteristics. Tissue specimens were handled in a standardized fashion using onsite evaluation, touch and smear preparation, and cell block tissue collection. Specimens were independently evaluated by 2 expert cytopathologists blinded to the diagnosis in each case. They assessed cytological yield (on smears) and histologic yield (on cellblock) using a previously validated standard scoring system reached by a consensus among our cytopathologists. RESULTS: A total of 75 patients (42 males, median age = 65 years) with solid pancreatic lesions underwent EUS-FNB during the study period: 50 using a 25G and 25 using 22G needle. There was no significant difference in the size or final cytopathological diagnosis of the lesions between the 2 groups (Table 1). Similarly, cytological scores of smears were comparable between the 2 groups. Due to the 25G needle’s increased flexibility in locations that entailed excessive scope angulation, it was utilized more for lesion sampling in the pancreatic head and uncinate process (70% vs 52%, P = 0.012). There was a statistically significant increase in diagnostic yield seen in the 25G group compared to the 22G (98% vs 88%. P = 0.013). The number of passes for cytological smears between both groups were similar; however, the 25G group required additional passes to obtain an adequate cell-block (1.6 vs 0.4, P = 0.001). CONCLUSION: We found the 25G FNB needle to be associated with superior diagnostic adequacy over 22G needles. This is consistent with FNA literature comparing these two common needle sizes. We noted an increased number of passes required in the 25G group to develop a cell block. This is likely due to the smaller size needle requiring more passes to build up an adequate cell block.

INTRODUCTION: Previously, surgical management represented the mainstay of therapy for esophageal defects such as tracheoesophageal fistulas, perforations, and post-operative leaks. As technical improvements in devices and endoscopic techniques improved, non-surgical management options increased to include clips, fibrin glue, and endoscopic suturing. Hybrid therapy involving both primary closure of the defect with endoscopic suturing and esophageal stent placement to protect the site was investigated. METHODS: We report a single center experience on dual modal therapy with endoscopic suturing and esophageal stenting for management of esophageal defects including tracheoesophageal fistulas, perforations, and post-operative leaks from 2013 to 2019. Factors such as etiology of defect (spontaneous perforation, iatrogenic perforation, tracheoesophageal fistula), size of defect, prior esophageal surgeries, and other factors were evaluated. Resolution was confirmed using esophagram to rule out leaks. RESULTS: 18 patients underwent dual modality therapy with primary closure using endoscopic suturing with concurrent esophageal stenting. Mean length of defects was 14.5 mm. 2 patients were lost to followup, and 1 patient was excluded because they underwent thoracostomy for concomitant therapy. Of the 15 patients left for analysis, successful closure was achieved in 14 patients.There were no significant complications related to the procedures. CONCLUSION: Early data from dual modality therapy from our single center report appear positive, however, there have not been enough cases to provide sufficient statistical analysis. Still, our combined approach show promising rates of success with minimal adverse effects. Further investigation comparing dual modality therapy with standard therapy are planned to be performed.