Clinical predictive value of renalase in post-ERCP pancreatitis

BACKGROUND AND AIMS

Plasma levels of renalase decrease in acute experimental pancreatitis. We aimed to determine if decreases in plasma renalase levels after ERCP predict the occurrence of post-ERCP pancreatitis (PEP).

METHODS

In this prospective cohort study conducted at a tertiary hospital, plasma renalase was determined before ERCP (baseline) and at 30 and 60 minutes after ERCP. Native renalase levels, acidified renalase, and native-to-acidified renalase proportions were analyzed over time using a longitudinal regression model.

RESULTS

Among 273 patients, 31 developed PEP. Only 1 PEP patient had a baseline native renalase >6.0 μg/mL, whereas 38 of 242 without PEP had a native renalase > 6.0 μg/mL, indicating a sensitivity of 97% (30/31) and specificity of 16% (38/242) in predicting PEP. Longitudinal models did not show differences over time between groups.

CONCLUSIONS

Baseline native renalase levels are very sensitive for predicting PEP. Further studies are needed to determine the potential clinical role of renalase in predicting and preventing PEP.

Endoscopic Ultrasound in Cancer Staging

The authors review the role of endoscopic ultrasound (EUS) in the staging of cancers throughout the gastrointestinal tract. EUS offers an advantage over cross-sectional imaging in locoregional tumor staging but is less sensitive in identifying distant metastasis. The addition of FNA increases diagnostic accuracy and provides a tissue diagnosis. EUS combined with cross-sectional imaging is important in accurately staging GI tumors and thereby reducing unnecessary procedures and health care costs.

Outcomes of cold snare endoscopic mucosal resection of nonampullary duodenal adenomas ≥1 cm: a multicenter study

BACKGROUND AND AIMS

Endoscopic mucosal resection (EMR) with use of electrocautery (conventional EMR) has historically been used to remove large duodenal adenomas; however, use of electrocautery can predispose to adverse events including delayed bleeding and perforation. Cold snare EMR (cs-EMR) has been shown to be safe and effective for removal of colon polyps, but data regarding its use in the duodenum are limited. The aim of this study was to evaluate the efficacy and safety of cs-EMR for nonampullary duodenal adenomas ≥1 cm.

METHODS

This was a multicenter retrospective study of patients with nonampullary duodenal adenomas ≥1 cm who underwent cs-EMR from October 2014 to May 2023. Patients who received any form of thermal therapy were excluded. Primary outcomes were technical success and rate of recurrent adenoma. Secondary outcomes were adverse events and predictors of recurrence.

RESULTS

A total of 125 patients underwent resection of 127 nonampullary duodenal adenomas with cs-EMR. Follow-up data were available in 89 cases (70.1%). The recurrent adenoma rate was 31.5% (n = 28). Adverse events occurred in 3.9% (n = 5), with 4 cases of immediate bleeding (3.1%) and 1 case of delayed bleeding (.8%). There were no cases of perforation. The presence of high-grade dysplasia was found to be an independent predictor of recurrence (odds ratio, 10.9 [95% confidence interval, 1.1-102.1]; P = .036).

CONCLUSIONS

This retrospective multicenter study demonstrates that cs-EMR for nonampullary duodenal adenomas is safe and technically feasible with an acceptable recurrence rate. Future prospective studies are needed to directly compare outcomes of cs-EMR with conventional and underwater EMR.

Improving Pancreatic Cyst Management: Artificial Intelligence-Powered Prediction of Advanced Neoplasms through Endoscopic Ultrasound-Guided Confocal Endomicroscopy

Despite the increasing rate of detection of incidental pancreatic cystic lesions (PCLs), current standard-of-care methods for their diagnosis and risk stratification remain inadequate. Intraductal papillary mucinous neoplasms (IPMNs) are the most prevalent PCLs. The existing modalities, including endoscopic ultrasound and cyst fluid analysis, only achieve accuracy rates of 65-75% in identifying carcinoma or high-grade dysplasia in IPMNs. Furthermore, surgical resection of PCLs reveals that up to half exhibit only low-grade dysplastic changes or benign neoplasms. To reduce unnecessary and high-risk pancreatic surgeries, more precise diagnostic techniques are necessary. A promising approach involves integrating existing data, such as clinical features, cyst morphology, and data from cyst fluid analysis, with confocal endomicroscopy and radiomics to enhance the prediction of advanced neoplasms in PCLs. Artificial intelligence and machine learning modalities can play a crucial role in achieving this goal. In this review, we explore current and future techniques to leverage these advanced technologies to improve diagnostic accuracy in the context of PCLs.

EUS-guided Gastroenterostomy: A Multicenter International Study Comparing Benign and Malignant Diseases

BACKGROUND

Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for patients with gastric outlet obstruction without the risks of surgical bypass and the limited long-term efficacy of enteral self-expanding metal stent placement. However, due to its novelty, there is a lack of significant data comparing long-term outcomes of patients with EUS-GE, based on the underlying disease. In this study, we compare outcomes of EUS-GE on benign versus malignant indications.

METHODS

Consecutive patients from 12 international, tertiary care centers who underwent EUS-GE over 3 years were extracted in a retrospective registry. Demographic characteristics, procedure-related information and follow-up data was collected. Primary outcome was the rate of adverse events associated with EUS-GE and the comparison of the rate of adverse events in benign versus malignant diseases. Secondary outcomes included technical and clinical success as well as hospitalization admission.

RESULTS

A total of 103 patients were included: 72 malignant and 31 benign. The characteristics of the patients undergoing EUS-GE is shown in Table 1. The mean age of the cohort was 68 years and 58 years for malignant and benign etiology. Gender distribution was 57% and 39% being females in malignant and benign etiology group, respectively. Clinical success, technical success, average procedure time, and hospital length of stay were similar in both groups. Patients with benign underlying etiology had significantly higher number of surgically altered midgut anatomy (P=0.0379).

CONCLUSION

EUS-GE is equally efficient regardless of the underlying etiology (malignant vs. benign), and the adverse events both groups were comparable.

Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium

INTRODUCTION

The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort.

METHODS

We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP.

RESULTS

There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier.

CONCLUSIONS

Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.

Novel 15-mm-long lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections located ≥10 mm from the luminal wall

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away.

METHODS

This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence.

RESULTS

35 patients (median age 57 years; interquartile range [IQR] 47-64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64-117) maximal diameter and located 11.8 mm (IQR 10-12.3; range 10-14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58-236). Three complications occurred (9 %; one mild, two moderate).

CONCLUSIONS

The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10-14 mm from the luminal wall.

Comorbidities Drive the Majority of Overall Mortality in Low-Risk Mucinous Pancreatic Cysts Under Surveillance

BACKGROUND & AIMS

The Charlson Comorbidity Index (CACI) has been suggested as a tool to determine comorbidity burden and guide management for patients with mucinous pancreatic cysts (Intrapapillary Mucinous Neoplasms and Mucinous Cystic Neoplasms), but has not been studied well among "low-risk" mucinous pancreatic cysts i.e. without worrisome features (WF) and high-risk stigmata (HRS). This study sought to determine the comorbidity burden among surveillance population of low-risk pancreatic cysts and provide their follow-up mortality outcomes.

METHODS

A single center study retrospectively reviewed a prospective pancreatic cyst database and included individuals with low-risk cysts undergoing serial imaging during 2016. Electronic medical records were reviewed to determine their baseline age-adjusted CACI (age-CACI). After 4 years, their progression to WF, disease specific (pancreatic malignancy-related, DSM), extra-pancreatic (EPM), and overall mortalities (OM) were determined using Kaplan-Meir Survival Analysis.

RESULTS

502 individuals underwent prospective surveillance. The study included 440 individuals with low-risk suspected or presumed mucinous cysts and excluded 50 and 12 individuals with WF and HRS respectively. Over a median follow-up of 56 months, 12 WF progressions, 2 DSMs, 42 EPMs, and 44 OMs were observed. Baseline age-CACI had good predictive capacity for 4-year EPM (Area-Under Curve: 0.87; p< .0001). The median age-CACI of 4 enabled cohort stratification into Low (age-CACI <4) and High CACI (age-CACI ≥4) groups. A significantly higher OM (p< .001) was observed among the High CACI group as compared to the Low CACI group.

CONCLUSION

Through real-time application of CACI to patient outcomes, our analysis supports incorporation of this comorbidity assessment tool in making shared surveillance decisions among low-risk pancreatic cyst population.

Massive Air Embolism Following Necrotizing Pancreatitis and COVID-19 Infection-The Role of Postmortem Computed Tomography

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that caused the COVID-19 pandemic raised important questions about workplace exposures to the virus, including postmortem exposures. The complexity of COVID-19 disease and its numerous unanticipated complications made autopsy even more vital in determining the pathophysiology of the disease. Performing traditional autopsy, however, carries risk of exposure. The following report describes an unusual case in which a patient diagnosed with COVID-19 and necrotizing pancreatitis underwent postmortem computed tomography (PMCT) prior to limited traditional autopsy and was unexpectedly found via PMCT to have large and diffuse venous air emboli and a new peripancreatic hematoma. In this case, not only did PMCT play a crucial role in determining the cause of death but also it allowed for a limited autopsy, thereby reducing the exposure to SARS-CoV-2 and associated risk to the autopsy staff and pathologists.

Double pigtail stent placement as an adjunct to lumen-apposing metal stents for drainage of pancreatic fluid collections may not affect outcomes: A multicenter experience

Background and Objectives:

EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention.

Methods:

We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS.

Results:

There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates.

Conclusion:

This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.

Ileosigmoid Anastomotic Perforation Three Weeks After Placement of Lumen-Apposing Metal Stent (LAMS)

Benign anastomotic intestinal strictures are difficult to manage as there may be limited response to dilation. Fully covered self-expanding metal stents have been utilized in small case series; however, stent suturing is required due to the high risk of stent migration. Lumen-apposing metal stents (LAMS) are fully covered and have a novel dumbbell shape that prevents stent migration. Initial reports identify low migration rates and good clinical success rates. This is the first report of perforation following treatment of an ileosigmoid stricture in a 52-year-old female, three weeks after LAMS placement.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Education and gastroenterology fellow knowledge about endoscopic mucosal resection of colon adenomas: a survey-based study

Background and study aims  Endoscopic mucosal resection (EMR) is an effective way to remove large (> 2 cm) colon adenomas. Training about it has not been standardized in fellowship programs. This study was aimed at evaluating the education and knowledge of gastroenterology fellows about EMR of colorectal adenomas. Methods  Participation in this survey was offered to 1730 gastroenterology fellows in the United States during the academic year 2019 to 2020. The survey assessed endoscopic mucosal resection training and knowledge and was approved and administered by the American College of Gastroenterology. Results  A total of 163 fellows (9.4 %) completed the survey. Only 85 fellows (52.1 %) reported receiving formal education in endoscopic mucosal resection. Fellow confidence was lowest regarding knowing electrosurgery unit settings. Fewer fellows correctly identified Paris 0-IIb (79, 48.5 %; P  < 0.0001) or NICE I (114, 69.9 %; P  < 0.01) lesions as compared to other Paris and NICE III lesions, respectively. Only 73 (44.8 %) and 93 fellows (57.1 %) arranged steps of EMR in the correct order and identified the correct type of current used for resection, respectively. Training year, male sex, and provision of advanced endoscopy rotations during fellowship were associated with a higher knowledge score for EMR. Conclusions  Nearly half of all fellows reported no formal education in EMR and incorrectly ordered its steps. Adenoma assessment by Paris and NICE classifications and electrosurgery unit settings were the most prominent knowledge deficiencies. Incorporation of standardized training about EMR with inclusion of advanced endoscopy rotations appears to be an important educational opportunity during gastroenterology fellowship.

Endoscopic ultrasound (EUS) and the management of pancreatic cancer

Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.

Prospective evaluation of an assessment tool for technical performance of duodenoscopes

OBJECTIVE

While single-use and detachable-tip duodenoscopes have been recently developed to overcome risks of infection transmission, there are no reliable tools to objectively assess their technical performance. We evaluated the reliability and validity of a newly developed tool to assess the technical performance of reusable duodenoscopes.

METHODS

An assessment tool was developed to measure duodenoscope performance based on three distinct criteria: maneuverability, mechanical/imaging characteristics and ability to perform requisite interventions. The assessment tool was tested prospectively on duodenoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures at nine academic medical centers over a 6-month period. The main outcome was reliability of the duodenoscope assessment tool, which was estimated using Cronbach's coefficient alpha (α). The secondary outcome was validity of the assessment tool.

RESULTS

The assessment tool evaluated technical performance of reusable duodenoscopes in 1080 ERCP procedures. Indications were biliary in 92.8% and pancreatic in 7.2% procedures. The overall Cronbach's coefficient α for maneuverability was 0.81, assessment of mechanical/imaging characteristics was 0.92, and ability to perform requisite interventions was 0.87. On multiple linear regression analysis, prolonged procedure duration, older patient age and pancreatic interventions were significantly positively associated with higher (worse) scores.

CONCLUSIONS

The newly developed assessment tool appears reliable and valid for evaluating the technical performance of duodenoscopes. Registration: ClinicalTrials.gov Identifier: NCT04004533.

Resection of pancreatic cystic neoplasms in recurrent acute pancreatitis prevents recurrent pancreatitis but does not identify more malignancies

BACKGROUND

Recurrent acute pancreatitis (RAP) may be a presenting feature of and an indication for resection of pancreatic cysts, including intra-ductal papillary mucinous neoplasm (IPMN). Few data are available regarding the prevalence of malignancy and post-operative RAP in this population.

AIM

To study the role of resection to help prevent RAP and analyze if presentation as RAP would be a predictor for malignancy.

METHODS

This retrospective study assessed 172 patients who underwent surgical resection of pancreatic cystic neoplasms at a university hospital between 2002 and 2016. The prevalence of preoperative high-risk cyst features, and of neoplasia was compared between patients with and without RAP. To identify the cause of pancreatitis, all the patients had a detailed history of alcohol, smoking, medications obtained, and had cross-sectional imaging (contrast-enhanced computed tomography/magnetic resonance imaging) and endoscopic ultrasound to look for gallstone etiology and other structural causes for pancreatitis. The incidence of RAP post-resection was the primary outcome.

RESULTS

IPMN accounted for 101 cases (58.7%) {[branch duct (BD) 59 (34.3%), main duct (MD) 42] (24.4%)}. Twenty-nine (16.9%) presented with RAP (mean 2.2 episodes): 15 had BD-IPMN, 8 MD-IPMN, 5 mucinous cystic neoplasm and 1 serous cystic neoplasm. Malignancy was similar among those with vs without RAP for all patients [6/29 (20.7%) vs 24/143 (16.8%)] and IPMN patients [6/23 (26.1%) vs 23/78 (29.5%)], although tended to be higher with RAP in BD-IPMN, [5/15 (33.3%) vs 3/44 (6.8%), P = 0.04]. At mean follow-up of 7.2 years, 1 (3.4%) RAP patient had post-resection RAP. The mean episodes of acute pancreatitis before vs after surgery were 3.4 vs 0.02 (P < 0.0001).

CONCLUSION

Malignancy was not increased in patients with pancreatic cystic neoplasms who have RAP compared to those without RAP. In addition, specific cyst charac-teristics were not clearly associated with RAP. The incidence of RAP was markedly decreased in almost all patients following cyst resection.

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy

BACKGROUND

While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis.

METHODS

Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment.

RESULTS

A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001).

CONCLUSION

Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

Role of Prophylactic Cholecystectomy After Endoscopic Sphincterotomy for Biliary Stone Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the effectiveness and complication rate of cholecystectomy deferral versus prophylactic cholecystectomy among patients post-endoscopic biliary sphincterotomy for common bile duct stones.

BACKGROUND

Although previous reports suggest a decreased risk of biliary complications with prophylactic cholecystectomy, biliary endoscopic cholangiopancreatography (ERCP) with sphincterotomy may provide a role for deferring cholecystectomy with the gallbladder left in situ.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through August 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Measured outcomes included: mortality, recurrent biliary pain or cholecystitis, pancreatitis, cholangitis, and eventual need for cholecystectomy. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs).

RESULTS

Nine studies (n = 1605) were included. A total of 53.8% (n = 864) patients had deferred cholecystectomy post-sphincterotomy. Deferral cholecystectomy as compared to prophylactic cholecystectomy resulted in a significant increased risk of mortality [odds raio (OR) 2.56 (95% confidence interval, CI 1.54-4.23); P < 0.0001; I2 = 18.49]. Patients who did not undergo prophylactic cholecystectomy developed more recurrent biliary pain or cholecystitis [OR 5.10 (95% CI 3.39-7.67); P < 0.0001; I2 = 0.00]. Rate of pancreatitis [OR 3.11 (95% CI 0.99-9.83); P = 0.053; I2 = 0.00] and cholangitis [OR 1.49 (95% CI 0.74-2.98); P = 0.264; I2 = 0.00] was unaffected. Overall, 26.00% (95% CI 14.00-40.00) of patients with deferred prophylactic cholecystectomy required eventual cholecystectomy.

CONCLUSIONS

Prophylactic cholecystectomy remains the preferred strategy compared to a deferral approach with gallbladder in situ post-sphincterotomy for patients with bile duct stones. Future studies may highlight a subset of patients (ie, those with large balloon biliary dilation) that may not require cholecystectomy.

Access fistulotomy: technical tips for success

Background and Aims

Biliary cannulation, although critical to procedural success in ERCP, can be difficult and, if unsuccessful, can lead to longer hospital stays, repeat procedures, and increased costs. Expertise in adjunct techniques, including access fistulotomy, can increase success rates and potentially avoid these issues. The aim of this case series is to describe the technique of access fistulotomy and illustrate key points that are important for successful biliary access.

Methods

Three cases are reviewed in which access fistulotomy was used to achieve biliary access. The steps for the procedure are reviewed, and key technical tips and anatomic landmarks are illustrated in the video.

Results

Successful biliary access is obtained using fistulotomy in 3 cases. In each case, the anatomic landmarks of the papilla and intraduodenal biliary segment are reviewed. The first case illustrates a large papilla in which initial incision followed by careful exposure reveals a clear “onion ring” structure corresponding to the bile duct. The second case requires stepwise incision, each guided by anatomic landmarks before the biliary adventitia is identified, leading to biliary cannulation. In the third case, the utility of fistulotomy in a duodenal diverticulum is illustrated. Recognition of the distorted anatomy allowed precise, careful incision leading to biliary access.

Conclusions

Access fistulotomy is an invaluable technique to aid in biliary access. Knowledge of key landmarks and careful evaluation of the incision are critical to successful biliary access when performing fistulotomy.

Endoscopic ultrasound-guided fine needle aspiration cytology diagnosis of upper gastrointestinal tract mesenchymal tumors: Impact of rapid onsite evaluation and correlation with histopathologic follow-up

BACKGROUND

Mesenchymal tumors (MTs) of upper gastrointestinal tract (UGIT) can show morphologic overlap thus posing a diagnostic challenge. This study evaluated the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology in the diagnosis of UGIT-MTs and impact of rapid onsite evaluation (ROSE).

METHODS

We retrospectively search our electronic database between January 2001 and August 2019 for cases that underwent EUS-FNA for a submucosal/or intramural upper GI tract mass forming lesions. Data pertinent to immunostain expression in UGIT-MTs was also collected.

RESULTS

We identified 139 cases, of which 72 cases had subsequent surgical resection. The cytologic diagnoses included nondiagnostic, negative, atypical, suspicious for neoplasm and positive for neoplasm (PFN) in 11, 7, 11, 10, and 100 cases, respectively. Diagnosis of PFN was rendered in 51 of 69 cases with ROSE (74%) and in 49 of 70 cases without ROSE (70%). However, the cases with ROSE had a higher percentage of cases being precisely classified than without ROSE (86% vs 61%, P < .05). On comparison of cytologic cases with cell block (CB) (n = 118) and without CB (n = 21), ROSE was performed in 67 (57%) and 2 (10%) cases, respectively (P < .01). All the cases with diagnosis of PFN were confirmed on subsequent surgical resection.

CONCLUSION

EUS-FNA has a diagnostic yield of 72% for UGIT-MTs. ROSE could improve diagnostic performance by further classifying MTs, probably via securing adequate lesional material for cell block for additional ancillary testing and precise diagnosis.

Constant-severe pain in chronic pancreatitis is associated with genetic loci for major depression in the NAPS2 cohort

BACKGROUND

Pain is the most debilitating symptom of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) and often requires chronic opioids or total pancreatectomy with islet autotransplantation to manage. Pain is a complex experience that can be exacerbated by depression and vice versa. Our aim was to test the hypothesis that depression-associated genes are associated with a constant-severe pain experience in RAP/CP patients.

STUDY

A retrospective study was done using North American Pancreatitis Study II (NAPS2) genotyped RAP and CP patients with completed case report forms (n = 1,357). Subjects were divided based on pattern of pain and pain severity as constant-severe pain (n = 787) versus not constant-severe pain (n = 570) to conduct a nested genome-wide association study. The association between reported antidepressant medication use and depression gene loci was tested.

RESULTS

Constant-severe pain was reported in 58% (n = 787) of pancreatitis patients. No differences in sex or alcohol consumption were found based on pain severity. Antidepressant use was reported in 28% (n = 223), and they had lower SF-12 mental quality of life (MCS, p < 2.2 × 10^- 16). Fifteen loci associated with constant-severe pain (p < 0.00001) were found to be in or near depression-associated genes including ROBO2, CTNND2, SGCZ, CNTN5 and BAIAP2. Three of these genes respond to antidepressant use (SGCZ, ROBO2, and CTNND2).

CONCLUSION

Depression is a major co-factor in the pain experience. This genetic predisposition to depression may have utility in counseling patients and in instituting early antidepressant therapy for pain management of pancreatitis patients. Prospective randomized trials are warranted.

CLINICAL TRIALS REGISTRATION

Clinicaltriasl.gov.# NCT01545167.

Low serum trypsinogen levels in chronic pancreatitis: Correlation with parenchymal loss, exocrine pancreatic insufficiency, and diabetes but not CT-based cambridge severity scores for fibrosis

BACKGROUND

Chronic pancreatitis (CP) is a complex inflammatory disorder of the pancreas affecting acinar cells, duct cells, islet cells and inflammatory cells including fibrosis-producing stellate cells. Serum trypsinogen is a biomarkers of acinar cell function.

AIM

To define the degree of correlation between low trypsinogen levels as a marker of acinar cell function and variable features of CP.

METHODS

Serum samples from previously ascertained and well phenotyped case and control subjects from the North American Pancreatitis Study II (NAPS2) were used to measure serum trypsinogen levels in a commercial laboratory. Control samples were used to define normal ranges and compared with levels in CP patients with defined features.

RESULTS

A final cohort of 279 CP patients and 262 controls from the NAPS2 studies were evaluated. In controls trypsinogen had a mean of 34.96 ng/ml and SD = 11.99. Cut-off values for low trypsinogen ranged from <20 to 10 ng/ml and very low trypsinogen at <10 ng/ml. Compared to controls, CP was associated with very low trypsinogen levels (p < 0.0001). Within CP, very low trypsinogen levels correlated with parenchymal loss (pancreatic surgery [p < 0.05]; atrophy with calcifications, [p < 0.001]), EPI (p < 0.01, trend p < 0.001) and diabetes (trend p < 0.01) but not CT-based criteria for fibrosis (pancreatic duct dilation, irregularity, strictures).

CONCLUSIONS

Very low serum trypsinogen levels correlate with measures of acinar cell loss including surgical resection, atrophic-calcific CP, diabetes and functional symptoms EPI but not duct morphology criteria. Serum trypsinogen levels correlate with decreased acinar cell function and therefore have biomarker utility clinical management.

Endoscopic Ultrasound-Guided, Percutaneous, and Transjugular Liver Biopsy: A Comparative Systematic Review and Meta-Analysis

Background/Aims

Percutaneous liver biopsy (PCLB) or transjugular liver biopsy (TJLB) have traditionally been performed to obtain a sample of hepatic tissue; however, endoscopic ultrasound-guided liver biopsy (EUSLB) has become an attractive alternative. The aim of this study was to compare the efficacy and safety of EUSLB, PCLB, and TJLB.

Methods

Search strategies were developed in accordance with PRISMA and MOOSE guidelines. Major outcomes included the following: adequacy of biopsy specimens (i.e., complete portal triads [CPT], total specimen length [TSL] in mm, and length of longest piece [LLP]) in mm), and rate of adverse events. Only studies comparing all biopsy approaches (i.e., EUSLB, PCLB, and TJLB) were included.

Results

Five studies (EUSLB [n=301]; PCLB [n=176]; and TJLB [n=179]) were included. Biopsy cumulative adequacy rates for EUSLB, PCLB, and TJLB were 93.51%, 98.27%, and 97.61%, respectively. Based on the subgroup analysis limited to EUS biopsy needles in current clinical practice, there was no difference in biopsy adequacy or adverse events for EUSLB compared to PCLB and TJLB (all p>0.050). A comparison of EUSLB and PCLB revealed no difference between specimens regarding both CPT (p=0.079) and LLP (p=0.085); however, a longer TSL (p<0.001) was observed. Compared to TJLB, EUSLB showed no difference in LLP (p=0.351), fewer CPT (p=0.042), and longer TSL (p=0.005).

Conclusions

EUSLB appears to be a safe, minimally invasive procedure that is comparable to PCLB and TJLB regarding biopsy specimens obtained and rate of adverse events associated with each method.

Alternative uses of lumen apposing metal stents

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White

Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.

Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis

Background and study aims  While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. Methods  A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringer's (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results  We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = - 0.69, 95 % CI [-1.18; - 0.21]), pancreatic stent (B = - 1.25, 95 % CI [-1.81 to -0.69]), LR (B = - 0.67, 95 % CI [-1.20 to -0.13]), and combination of LR plus rectal NSAIDs (B = - 1.58; 95 % CI [-3.0 to -0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment. Conclusions  Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.

Impact of endoscopic ultrasound on diagnosis and management of presumed mucinous neoplasms when done for pancreatic cyst morphology change on non-invasive surveillance imaging

Background and study aims  Guidelines for management of presumed neoplastic pancreatic cysts have encouraged noninvasive imaging for low-risk surveillance, while reserving endoscopic ultrasound for worrisome features including morphologic change. We aim to study the impact of endoscopic ultrasound on diagnosis and management compared with non-invasive imaging. Patients and methods  A single-institution pancreatic cyst database was retrospectively queried for patients who underwent endoscopic ultrasound for the indication of change in cyst morphology. Diagnoses were classified as presumed mucinous neoplasm with or without worrisome features or high-risk stigmata and non-mucinous lesions. Management decisions were defined a priori as surgical evaluation for patients with high-risk stigmata, positive cytology or mural nodule, or continued surveillance for all others. Results  Between January 2013 and October 2016, 709 pancreas cyst endoscopic ultrasounds were performed of which 89 were for cyst morphology change seen on noninvasive imaging including 10 presumed pseudocysts, nine presumed serous cystadenomas, and 70 presumed mucinous cystic neoplasms. Cyst morphologic changes included increase in caliber of the main pancreatic duct (7 cases), increase in cyst size (68 cases), cyst ≥ 30 mm (10 cases), and presence of a solid nodule (1 case). Median cyst size increase was 5 mm with interquartile range of 4 mm over 2.1 ± 1.9 years. Endoscopic ultrasound done for morphologic change resulted in a change in diagnosis and management in 16 % and 13 % of cases, respectively. Conclusion  Endoscopic ultrasound has a modest but clinically significant role in impacting diagnosis and management for presumed mucinous cystic neoplasms when performed for the indication of cyst morphology change.

Endoscopic Ultrasound for the Diagnosis and Staging of Liver Tumors

Endoscopic ultrasound examination may provide complementary information to cross-sectional imaging in lesions of the liver, portal vein, and surrounding lymph nodes. With fine needle aspiration, endoscopic ultrasound examination is a powerful tool for the diagnosis of focal liver lesions and has usefulness in the evaluation of indeterminate liver lesions. Endoscopic ultrasound examination may influence hepatocellular cancer staging and Endoscopic ultrasound examination with fine needle aspiration of locoregional nodes and portal vein thromboses changes management. Contrast-enhanced endoscopic ultrasound examination and endoscopic ultrasound examination elastography are likely to expand the usefulness of endoscopic ultrasound examination in evaluating liver malignancy with technologic improvements.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study

Background and study aims  Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS.  Patients and methods  Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression. Results  A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) ( P  < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively ( P  = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 - 51.82, P  = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion. Conclusions  EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.

Nutrition and Inflammatory Biomarkers in Chronic Pancreatitis Patients

BACKGROUND

Chronic pancreatitis (CP) patients frequently experience malabsorption and maldigestion, leading to micronutrient and macronutrient deficiencies. Comorbid diabetes and lifestyle habits, such as alcohol consumption, may impact nutrition status.

METHODS

We compared micronutrient antioxidant, bone metabolism, serum protein, and inflammatory marker levels in 301 CP patients and 266 controls with no known pancreatic disease. We analyzed serum prealbumin and retinol binding protein; vitamins A, D, E, and B12; osteocalcin; tumor necrosis factor-α; and C-reactive protein (CRP). We also evaluated biomarkers among subsets of patients, examining factors including time since diagnosis, body mass index, alcohol as primary etiology, diabetes mellitus, vitamin supplementation, and pancreatic enzyme replacement.

RESULTS

After correcting for multiple comparisons, CP patients had significantly lower levels than controls of the following: vitamin A (40.9 vs 45.4 μg/dL) and vitamin E (α-tocopherol [8.7 vs 10.3 mg/L] and γ-tocopherol [1.8 vs 2.2 mg/L]), as well as osteocalcin (7.9 vs 10 ng/mL) and serum prealbumin (23 vs 27 mg/dL). Both patients and controls who took vitamin supplements had higher serum levels of vitamins than those not taking supplements. Compared with controls, in controlled analyses, CP patients had significantly lower levels of vitamins A, D, and E (both α-tocopherol and γ-tocopherol). CP patients also had significantly lower levels of osteocalcin, serum prealbumin, and retinol binding protein, and higher CRP.

CONCLUSIONS

CP patients demonstrated lower levels of selected nutrition and bone metabolism biomarkers than controls. Diabetes and alcohol did not impact biomarkers. Vitamin supplements and pancreatic enzyme replacement therapy improved nutrition biomarkers in CP patients.

Known genetic susceptibility factors for chronic pancreatitis in patients of European ancestry are rare in patients of African ancestry

BACKGROUND

Multiple pathogenic genetic variants are associated with pancreatitis in patients of European (EA) and Asian ancestries, but studies on patients of African ancestry (AA) are lacking. We evaluated the prevalence of known genetic variations in African-American subjects in the US.

METHODS

We studied prospectively enrolled controls (n = 238) and patients with chronic (CP) (n = 232) or recurrent acute pancreatitis (RAP) (n = 45) in the NAPS2 studies from 2000-2014 of self-identified AA. Demographic and phenotypic information was obtained from structured questionnaires. Ancestry and admixture were evaluated by principal component analysis (PCA). Genotyping was performed for pathogenic genetic variants in PRSS1, SPINK1, CFTR and CTRC. Prevalence of disease-associated variants in NAPS2 subjects of AA and EA was compared.

RESULTS

When compared with CP subjects of EA (n = 862), prevalence of established pathogenic genetic variants was infrequent in AA patients with CP, overall (29 vs. 8.19%, OR 4.60, 95% CI 2.74-7.74, p < 0.001), and after stratification by alcohol etiology (p < 0.001). On PCA, AA cases were more heterogeneous but distinct from EA subjects; no difference was observed between AA subjects with and without CP-associated variants. Of 19 A A patients with CP who had pathogenic genetic variants, 2 had variants in PRSS1 (R122H, R122C), 4 in SPINK1 (all N34S heterozygotes), 12 in CFTR (2 CFTR^sev, 9 CFTR^BD, 1 compound heterozygote with CFTR^sev and CFTR^BD), and 1 in CTRC (R254W).

CONCLUSION

Pathogenic genetic variants reported in EA patients are significantly less common in AA patients. Further studies are needed to determine the complex risk factors for AA subjects with pancreatitis.

Recurrent Acute Pancreatitis Significantly Reduces Quality of Life Even in the Absence of Overt Chronic Pancreatitis

OBJECTIVES

The impact of recurrent acute pancreatitis (RAP) on quality of life (QOL) is unknown. We hypothesized that RAP would reduce QOL even in the absence of chronic pancreatitis (CP).

METHODS

Data were pooled from three prospective, cross-sectional studies conducted across 27 U.S. centers (the North American Pancreatitis Studies); these included subjects with chronic pancreatitis (n = 1086), RAP alone (n = 508), and non-disease controls (n = 1025). QOL was measured using the Short Form 12 (SF-12), generating a Physical Component Summary (PCS) and the Mental Component Summary score (MCS). Multivariable regression models were developed to measure the effect of RAP on QOL, the predictors of lower QOL in those with RAP, and the differential effect QOL predictors between CP and RAP.

RESULTS

Compared to controls (51.0 ± 9.4), subjects with RAP (41.1 ± 11.4) and CP (37.2 ± 11.8) had lower PCS (p < 0.01). Subjects with CP had lower PCS compared to those with RAP (p < 0.01). Similarly, MCS was lower among RAP (44.6 ± 11.5) and CP (42.8 ± 12.2) subjects compared to controls (51.7 ± 9.1, p < 0.01). Subjects with CP had lower MCS compared to those with RAP (p < 0.01). After controlling for independent predictors of PCS, RAP was associated with lower PCS (estimate -8.46, p < 0.01) and MCS (estimate -6.45, p < 0.0001) compared to controls. The effect of endocrine insufficiency on PCS was differentially greater among RAP subjects (-1.28 for CP vs. -4.9 for RAP, p = 0.0184).

CONCLUSIONS

Even in the absence of CP, subjects with RAP have lower physical and mental QOL. This underscores the importance of identifying interventions to attenuate RAP before the development of overt CP.