New advances in pancreatic imaging

Preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: A prospective study

Background

Characterisation of pancreatic cystic lesions has a direct role in their management and computed tomography is the mainstay of investigation for diagnosing and characterising them.

Objectives

The aim of this study was to prospectively assess the diagnostic accuracy of contrast-enhanced computed tomography (CECT) in preoperative characterisation of pancreatic cystic lesions with histopathology as the reference standard.

Method

A total of 38 patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were preoperatively evaluated with CECT. Images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images and overall diagnostic accuracy calculated. Imaging findings were compared with histopathology, or cytology and/or intra-operative findings.

Results

Serous cystadenoma (SCA) was the most common cystic pancreatic lesion found in 31.6% of patients followed by mucinous cystadenoma (MCA) (26.3%), solid pseudo-papillary tumour (SPT) (21.1%) and intra-ductal papillary mucinous neoplasm (IPMN) (10.5%). Three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. The diagnostic accuracy of CECT for pancreatic cystic lesions was found to be 72.5.

Conclusion

The diagnostic accuracy of computed tomography (CT) was high for SCA, IPMN and pancreatic cysts, and low for MCA and SPT. Combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for SCA. Unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards MCA. Solid cystic pancreatic head lesions in young females may be suggestive of SPT. A dilated main pancreatic duct in a cystic lesion with internal septations may point towards IPMN. Fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. Lastly, pseudocysts and neuroendocrine tumours with cystic components are great mimickers of pancreatic cystic lesions, and a history of pancreatitis and hormonal profile of patients should always be sought.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

[Pancreatic tumors]

The management of pancreatic cancer is complex and prognosis is poor. The etiopathogenesis of pancreatic cancer has been related to several factors, such as diabetes mellitus, smoking and alcohol use, the presence of pancreatic cystic lesions and distinct genetic syndromes. Among the diagnostic options, endoscopic ultrasound (EUS) continues to be developed, with the use of elastography, contrast agents and EUS-guided aspiration and the application of technical improvements that increase diagnostic efficacy (such as the use of specific stains, new aspiration needles, etc.). New biomarkers are also being sought that would help in differential diagnosis, such as M2PK, adiponectin, and Reg4. Among prognostic factors, the importance of nodal involvement and study of surgical resection margins has been confirmed. The role of individual predisposition in determining response to specific treatments continues to be investigated. Research also continues into the development of EUS-guided injection of therapeutic substances and the role of oncological treatment, with new data on the utility of gemcitabine and of statins as mediators of angiogenic suppression or of high-dose vitamin C with cytotoxic effects. Notable in the field of palliative treatment is the development of new biliary stents that aim to reduce obstruction rates. The development of EUS and EUS-guided fine-needle aspiration has been crucial in cystic pancreatic tumors, especially in distinguishing benign from malignant lesions or those with potential for malignant transformation (presence of mural modules, dilatation of the main pancreatic duct, the presence of masses, CEA levels, etc.). The characteristics of these tumors must be determined to evaluate whether surgery or conservative management is the best therapeutic option.

Acute recurrent pancreatitis: An autoimmune disease?

In this review article, we will briefly describe the main characteristics of autoimmune pancreatitis and then we will concentrate on our aim, namely, evaluating the clinical characteristics of patients having recurrence of pain from the disease. In fact, the open question is to evaluate the possible presence of autoimmune pancreatitis in patients with an undefined etiology of acute pancreatitis and for this reason we carried out a search in the literature in order to explore this issue. In cases of recurrent attacks of pain in patients with “diopathic”pancreatitis, we need to keep in mind the possibility that our patients may have autoimmune pancreatitis. Even though the frequency of this disease seems to be quite low, we believe that in the future, by increasing our knowledge on the subject, we will be able to diagnose an ever-increasing number of patients having acute recurrence of pain from autoimmune pancreatitis.

Emergency laparoscopy--current best practice

Emergency laparoscopic surgery allows both the evaluation of acute abdominal pain and the treatment of many common acute abdominal disorders. This review critically evaluates the current evidence base for the use of laparoscopy, both diagnostic and interventional, in the emergency abdomen, and provides guidance for surgeons as to current best practise. Laparoscopic surgery is firmly established as the best intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies but requires further randomised controlled trials to definitively establish its role in other conditions.