Evaluating the role of endoscopic ultrasound in pancreatitis

Management of Pancreatic Duct Strictures, Leaks, and Disconnected Pancreatic Duct Syndrome

Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

Retrospective analysis of pathological types and imaging features in pancreatic cancer: A comprehensive study

BACKGROUND

Pancreatic cancer remains one of the most lethal malignancies worldwide, with a poor prognosis often attributed to late diagnosis. Understanding the correlation between pathological type and imaging features is crucial for early detection and appropriate treatment planning.

AIM

To retrospectively analyze the relationship between different pathological types of pancreatic cancer and their corresponding imaging features.

METHODS

We retrospectively analyzed the data of 500 patients diagnosed with pancreatic cancer between January 2010 and December 2020 at our institution. Pathological types were determined by histopathological examination of the surgical specimens or biopsy samples. The imaging features were assessed using computed tomography, magnetic resonance imaging, and endoscopic ultrasound. Statistical analyses were performed to identify significant associations between pathological types and specific imaging characteristics.

RESULTS

There were 320 (64%) cases of pancreatic ductal adenocarcinoma, 75 (15%) of intraductal papillary mucinous neoplasms, 50 (10%) of neuroendocrine tumors, and 55 (11%) of other rare types. Distinct imaging features were identified in each pathological type. Pancreatic ductal adenocarcinoma typically presents as a hypodense mass with poorly defined borders on computed tomography, whereas intraductal papillary mucinous neoplasms present as characteristic cystic lesions with mural nodules. Neuroendocrine tumors often appear as hypervascular lesions in contrast-enhanced imaging. Statistical analysis revealed significant correlations between specific imaging features and pathological types (P < 0.001).

CONCLUSION

This study demonstrated a strong association between the pathological types of pancreatic cancer and imaging features. These findings can enhance the accuracy of noninvasive diagnosis and guide personalized treatment approaches.

Enhancing physician support in pancreatic cancer diagnosis: New M-F-RCNN artificial intelligence model using endoscopic ultrasound

Background and study aims Endoscopic ultrasound (EUS) is vital for early pancreatic cancer diagnosis. Advances in artificial intelligence (AI), especially deep learning, have improved medical image analysis. We developed and validated the Modified Faster R-CNN (M-F-RCNN), an AI algorithm using EUS images to assist in diagnosing pancreatic cancer. Methods We collected EUS images from 155 patients across three endoscopy centers from July 2022 to July 2023. M-F-RCNN development involved enhancing feature information through data preprocessing and utilizing an improved Faster R-CNN model to identify cancerous regions. Its diagnostic capabilities were validated against an external set of 1,000 EUS images. In addition, five EUS doctors participated in a study comparing the M-F-RCNN model's performance with that of human experts, assessing diagnostic skill improvements with AI assistance. Results Internally, the M-F-RCNN model surpassed traditional algorithms with an average precision of 97.35%, accuracy of 96.49%, and recall rate of 5.44%. In external validation, its sensitivity, specificity, and accuracy were 91.7%, 91.5%, and 91.6%, respectively, outperforming non-expert physicians. The model also significantly enhanced the diagnostic skills of doctors. Conclusions: The M-F-RCNN model shows exceptional performance in diagnosing pancreatic cancer via EUS images, greatly improving diagnostic accuracy and efficiency, thus enhancing physician proficiency and reducing diagnostic errors.

Clinical characteristics, imaging diagnostic accuracy, and prognosis of autoimmune pancreatitis: A real-world study in China

OBJECTIVE

In this study we aimed to comprehensively evaluate the clinical features and treatment outcomes of Chinese patients with autoimmune pancreatitis (AIP) through a single-center real-world study.

METHODS

Patients diagnosed with AIP in Changhai Hospital, Naval Medical University from January 2014 to December 2021 were included. Baseline characteristics, laboratory test results, cross-sectional imaging and endoscopic ultrasound (EUS) findings, and long-term follow-up data were obtained. The differences in these characteristics between type 1 and type 2 AIP patients were analyzed.

RESULTS

Among all 320 patients, 271 (84.7%) and 49 (15.3%) had type 1 and type 2 AIP, respectively. The most common initial symptom was abdominal discomfort (58.1%), followed by obstructive jaundice (32.5%). Extrapancreatic organ involvement was identified in 126 (39.4%) patients, with the biliary system being the most commonly involved (36.6%). Elevated serum IgG4 level was rare in type 2 AIP patients. The diagnostic accuracy of computed tomography (CT), magnetic resonance imaging (MRI), and EUS for definitive and probable AIP were 78.0%, 68.7%, and 80.5%, respectively. EUS-guided tissue acquisition with immunohistochemical staining helped establish a final diagnosis in 39.7% of patients. During the follow-up period of 60 months, 18.6% of patients experienced relapse. The 1-, 3-, and 5-year relapse rates were higher in type 1 AIP patients, with an accumulated rate of 8.0%, 12.6%, and 15.1%, when compared with those with type 2 AIP.

CONCLUSIONS

Type 2 AIP is not uncommon in Chinese population. The diagnostic accuracy of CT and EUS for AIP might be superior to that of MRI.

Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

[Interventional radiological and endoscopic technologies in diagnosis and treatment of chronic pancreatitis]

This review is devoted to internationally accepted diagnostic algorithms for complicated chronic pancreatitis (CP). In addition, the authors discuss interventional radiological and endoscopic diagnostic and therapeutic procedures, as well as their role in surgical approaches for this disease. Chronic pancreatitis is often diagnosed with severe symptoms following severe course of disease and complications. Imaging techniques, such as ultrasound, endoscopic ultrasound, CT, MRI/MR cholangiocreatography (MRCP), secretin-stimulated MRCP, are valuable to assess the pancreas in patients with initial manifestations of CP. Modern treatment of complicated CP includes transpapillary or transmural drainage of false cysts, shock wave lithotripsy and stenting for pancreatic duct strictures and/or stones, stenting for biliary hypertension, endovascular interventions for vascular complications and radical surgical treatment. Endoscopic methods are preferable regarding better short-term quality of life. Early surgical intervention (within 3 years after clinical manifestation) is effective to eliminate or significantly reduce pain and pancreatic insufficiency. Multidisciplinary team including surgeons, endoscopists and interventional radiologists should determine the most optimal diagnostic and treatment approach individually for each patient.

Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.

Endoscopic Ultrasound in Pancreatic Duct Anomalies

Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.

Endoscopic Ultrasound (EUS) Guided Elastography

Endoscopic ultrasound (EUS) is an essential technique for the management of several diseases. Over the years, new technologies have been developed to improve and overcome certain limitations related to EUS-guided tissue acquisition. Among these new methods, EUS-guided elastography, which is a real-time method for the evaluation of tissue stiffness, has arisen as one of the most widely recognized and available. At present, there are available two different systems to perform an elastographic evaluation: strain elastography and shear wave elastography. Strain elastography is based on the knowledge that certain diseases lead to a change in tissue hardness while shear wave elastography monitored shear-wave propagation and measures its velocity. EUS-guided elastography has shown in several studies high accuracy in differentiating benign from malignant lesions from many different locations, mostly in the pancreas and lymph nodes. Therefore, nowadays, there are well-established indications for this technology, mainly for supporting the management of pancreatic diseases (diagnosis of chronic pancreatitis and differential diagnosis of solid pancreatic tumors) and characterization of different diseases. However, there are more data on new potential indications for the near future. In this review, we will present the theoretical bases of this technology and we will discuss the scientific evidence to support its use.