EUS-FNA, combined with ROSE, is a safe and highly effective technique in experienced hands with excellent diagnostic accuracy and low complication rates.

Purpose: To evaluate the diagnostic yield of biliary brush cytology and the factors affecting positive results in patients with biliary strictures. Patients and Methods: The medical records of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary brush cytology at our institution from November 2004 to December 2013 were reviewed in this retrospective study. The yield of positive brush cytology and the factors affecting positive yield, such as stricture location, age, gender and preprocedure CA 19.9 level were assessed. The final histopathology, diagnosis obtained by other methods, such as endoscopic ultrasound-guided fine-needle aspiration cytology, CT scan, Tru-Cut biopsy and/or clinical/radiological follow-up were used to identify true- and false-positive/negative results. The brush cytology results were divided into 4 main categories: malignant, benign, atypical cells and inadequate. Results: A total of 1,168 patients underwent ERCP during this 9-year period. Out of these, 142 patients had ERCP and biliary brushings for diagnosis. The mean age of the patients at presentation was 58.7 years (range 23-84 years; 64.8% males). The indication for referral was obstructive jaundice in all patients. Of the 142 patients, 77 (54.2%) had a distal common bile duct (CBD) stricture and 65 (45.8%) had a proximal /complex hilar stricture. The strictures were classified as proximal or distal, based on their relationship with the cystic duct; those below the cystic duct insertion were classified as distal and those above it were considered proximal. The diagnostic yield of brush cytology was 58.5%. The diagnostic yield was higher for proximal than for distal CBD strictures (67 vs. 50%; p = 0.047). It was also higher for females (58 vs. 57.6%; p = 0.94), patients >50 years (60 vs. 50%; p = 0.29) and those with a CA 19.9 level >300 IU/ml (59.4 vs. 55.5%; p = 0.65) but did not reach statistical significance for any of these parameters. Complete follow-up data were available for 96 patients and 46 patients were lost to follow-up. The sensitivity, specificity, positive predictive value and negative predictive value were 65.3, 100, 100 and 27%, respectively. When patients with atypia were included in the group with positive results, the diagnostic yield increased to 65.5% with a diagnostic sensitivity of 68.6%. There were 27 false-negative diagnoses, 10 patients were true-negative and no patients had a false-positive diagnosis. Conclusion: Biliary brush cytology is a safe and simple initial diagnostic procedure in patients with biliary strictures and can be performed at the time of therapeutic ERCP. If performed correctly and then interpreted by a dedicated cytopathologist, it has a good diagnostic yield and sensitivity. We feel that the low rates of success with this technique reported in some earlier studies have led to a feeling that this is not a particularly useful technique. We recommend that this topic should be revisited, and that the technique should be used more often.

Introduction: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has proven to be helpful in obtaining tissue samples from enlarged mediastinal and intra-abdominal lymph nodes. This is especially beneficial in the diagnosis and staging of malignancy. We retrospectively reviewed the clinical utility of this method at a tertiary care cancer hospital in Pakistan. Patients and Methods: The medical records of 183 consecutive patients referred to the gastroenterology service from August 2008 to March 2012 were reviewed in this retrospective study. The mean age of the patients at presentation was 46.7 years (range 6-87; 62% males); 119 patients had mediastinal and 64 had intra-abdominal lymphadenopathy. Major indications for referral were diagnosis of lymphadenopathy of unknown origin detected on CT scan or PET-CT, to exclude lymph node metastasis in patients with a known primary tumor and to rule out relapse of lymphoma following treatment or during follow-up. Rapid on-site evaluation (ROSE) was performed in all patients to confirm the adequacy of sampling, followed by definitive cytopathological evaluation. Results: EUS-FNA with ROSE obtained adequate tissue for cytology in 97.3% of the patients in this cohort. These results were further confirmed on final cytopathological analysis in 96.2% of patients. Two patients (1.1%) had inadequate specimens for final interpretation (97.3 vs. 96.2; p = 0.001). Clinical utility was 95% for mediastinal lymphadenopathy and 98.4% for intra-abdominal lymphadenopathy. Only 1 patient had a serious complication requiring hospitalization and this was successfully managed conservatively. Conclusion: EUS-FNA is safe and has a high clinical utility in diagnosing unexplained mediastinal and intra-abdominal lymphadenopathy.

Background: The percutaneous endoscopic gastrostomy (PEG) tube in patients with oesophageal cancer is controversial, owing to a perceived risk of tumour seeding at the PEG site, theoretical difficulty in formation of gastric conduit during oesophagectomy and a fear of increased post-operative complications, including anastomotic leak. We aimed to assess the impact of PEG tubes on nutritional status and post-operative complications in patients with oesophageal cancer who underwent PEG tube insertion prior to neo-adjuvant treatment. Methods: We performed a retrospective review of 800 patients with oesophageal or gastro oesophageal junction (GOJ) cancer, who underwent PEG insertion from June, 2010 to May, 2015. Out of these, 168 patients who fulfilled the inclusion criteria were analysed further. All of them were followed up for 3 years after treatment to assess overall survival. Thus, the follow up of the last patient included in the study was completed on May, 31, 2018. Results: The average body mass index (BMI) of patients was maintained following PEG tube, during neoadjuvant treatment (22.34±4.84 before PEG vs. 21.85±3.90 after PEG, P value: 0.1). Out of 168 patients, 33 (19.7%) developed a complication following PEG tube, with PEG site infection as the most common in 24 (14.2%). PEG-related mortality at 1 month was 0%. Ninety out of 168 patients (59%) underwent surgery after neo-adjuvant treatment. Three patients had tumour seeding at the PEG site and thus surgery could not be performed. Gastric conduit formation was possible in all 99 patients. Postoperative complications were seen in 17/99 (17%) patients, including surgical site infections in 7 (7.07%), anastomotic leak in 6 (6.06%) and anastomotic stricture in 4 (4.04%). Overall survival at 3 years was 87%. Conclusions: Pre-operative PEG tube in oesophageal cancer is safe and does not compromise the future anastomosis. Also, it helps in maintaining the nutritional status during neo-adjuvant treatment.

The role of self-expandable metallic stents is gradually evolving for a diverse group of benign and malignant gastrointestinal tract problems, with luminal obstruction being by far the most common. Although its role in refractory variceal bleeding is well established, it has rarely been tried for tumor-related bleeding, with only a few case reports in this regard. We share our experience of successfully controlling esophageal tumor–related bleeding with the use of a fully covered self-expandable metallic stent. A 58-year-old woman with irresectable distal esophageal cancer, presented with hematemesis. Esophago-gastro-duodenoscopy revealed an obstructing esophageal tumor with diffuse oozing of blood. This was unamenable to local injection of adrenaline and hemospray; therefore, a temporary self-expandable metallic stent was parked to create a tamponade effect. This successfully stopped bleeding and the patient remained asymptomatic till discharge. However, she was lost to follow-up, and therefore, the stent was removed after a period of 5 months instead of 2 weeks.