Endoscopic retrograde access to the biliary tree is not always possible and endoscopic ultrasound (EUA)-guided biliary drainage is increasingly used. EUS-guided hepaticogastrostomy has been proved to be feasible, although safety issues still need to be evaluated. There are few reports [1-5] with 90 %-100 % technical and 75 %-100 % clinical success rates. Major complications included stent migration, bile leaks, and cholangitis [4, 5]. An 81-year-old man with obstructive jaundice secondary to gallbladder adenocarcinoma and duodenal stricture was referred for endoscopic drainage. Magnetic resonance imaging (MRI) showed an infiltrative mass and biliary stenosis with dilated intrahepatic ducts (• " Fig. 1). The duodenal stricture was dilated with a balloon. Following failure of several attempts at transpapillary deep cannulation of the bile duct, a decision was taken to carry out transgastric EUS-guided drainage. A linear EUS scope positioned in the gastric lesser curvature disclosed a dilated intrahepatic biliary system (• " Fig. 2 a), and a 19-gauge needle was inserted inside a left intrahepatic branch (• " Fig. 2 b). After stylet removal, a cholangiogram was obtained (• " Fig. 3) and a 0.035-inch guide wire was introduced through the needle (• " Video 1). The guide wire was then positioned into an intrahepatic biliary branch. The transmural tract was enlarged by using a needle-knife. A partially covered self-expandable metal stent (SEMS), 10 × 60 mm in size (Wallstent, Boston Scientific International, La Garenne Colombes, France), was inserted (• " Fig. 4). At the end of the procedure, an enteral SEMS, 30 × 90 mm in size (Wallflex, Boston Scientific), was placed across the duodenal stenosis (• " Fig. 5 and• " Video 1).

BackgroundResearch has shown that fecal biomarkers are useful to assess the activity of inflammatory bowel disease (IBD). The aim of the study is: to evaluate the efficacy of the fecal lactoferrin and calprotectin as indicators of inflammatory activity.FindingsA total of 78 patients presenting inflammatory bowel disease were evaluated. Blood tests, the Crohn's Disease Activity Index (CDAI), Mayo Disease Activity Index (MDAI), and Crohn's Disease Endoscopic Index of Severity (CDEIS) were used for the clinical and endoscopic evaluation. Two tests were performed on the fecal samples, to check the levels of calprotectin and lactoferrin. The performance of these fecal markers for detection of inflammation with reference to endoscopic and histological inflammatory activity was assessed and calculated sensitivity, specificity, accuracy.A total of 52 patient's samples whose histological evaluations showed inflammation, 49 were lactoferrin-positive, and 40 were calprotectin-positive (p = 0.000). Lactoferrin and calprotectin findings correlated with C-reactive protein in both the CD and UC groups (p = 0.006; p = 0.000), with CDAI values (p = 0.043; 0.010), CDEIS values in DC cases (p = 0,000; 0.000), and with MDAI values in UC cases (p = 0.000).ConclusionFecal lactoferrin and calprotectin are highly sensitive and specific markers for detecting intestinal inflammation. Levels of fecal calprotectin have a proportional correlation to the degree of inflammation of the intestinal mucosa.

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PURPOSE:To evaluate the diagnosis improvement of EUS-FNA when using ROSE performed by the endosonographer. METHODS:A retrospective study was conducted. A total of 48 pancreatic solid masses EUS-FNA were divided into two groups according to the availability of on-site cytology (ROSE) -the first 24 patients (group A-without ROSE) and the latter 24 cases (group B-with ROSE). Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, complications and inadequacy rate of EUS-FNA were determined and compared. RESULTS:Among the 48 EUS-FNA, the overall performance was: sensitivity 82%; specificity 100%; positive predictive value (PPV) 100%; negative predictive value (NPV) 70% and accuracy 87%. The sensitivity of the Group A was 71%, versus 94% in-group B (p=0.61). Moreover, the negative predictive value was 58% versus 87% (p=0.72). The accuracy rate increased from 79% to 96% (p=0.67) in the ROSE group. The number of punctures was similar between the groups. No major complications were reported. CONCLUSION:Rapid on-site cytopathological examination, even when performed by the endosonographer, may improve the diagnostic performance in the diagnosis of solid pancreatic lesions, regardless of the slight increase in the number of punctures.

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