Outcome of forgotten biliary stents for more than five years-A two-decade experience

BACKGROUND AND OBJECTIVES

Prolonged biliary stenting may lead to complications such as cholangitis, stentolith and stent migration. There is limited data on forgotten biliary stents for more than five years in literature. The aim of this retrospective study was to analyze the complications and outcomes in patients who forgot to get their biliary stents removed or exchanged for more than five years.

METHODS

The study population included patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and plastic biliary stent placements in a tertiary care center from 1990 to 2022 for benign biliary diseases. Loss to follow-up and subsequent forgotten stent for more than five years were observed in 40 patients who underwent ERCP during this study period. We retrospectively analyzed the indications of stenting, present status of stent, complications and outcomes in the study patients.

RESULTS

The mean age of the study patients was 51.5 ± 11.5 years with 27 females. Indications of biliary stent placement were choledocholithiasis (33, 82.5%), bile leak (3, 7.5%), benign biliary stricture (2, 5%) and choledochal cyst (2, 5%). The mean duration of forgotten stent was 5.9 ± 3.6 years. Presenting symptoms were abdominal pain (37, 92.5%), fever (26, 65%) and jaundice (32, 80%). Most commonly placed stent was 7 French double pigtail of 10 cm length. Complications in the study patients were cholangitis (35, 87.5%), internal migration (2, 5%), pancreatitis (1, 2.5%) and portal hypertension (1, 2.5%). The outcomes were stone removal (30, 90.9%), stent removal (31, 77.5%), stent reinsertion (19, 47.5%), broken stent (3, 7.5%) and surgery (2, 5%).

CONCLUSIONS

Prolonged duration (> 5 years) of forgotten stent is uncommon and is observed most commonly in patients with choledocholithiasis. The most common complication of long duration of forgotten stents was cholangitis followed by internal migration, pancreatitis and portal hypertension. Stone and stent removal was successful in a majority of patents, while surgery was required in less number of patients.

The Role Of Cytology In The Investigation And Management Of Pancreatobiliary Lesions With A Transition Towards A Standardised Reporting System: An Institutional Perspective

Pancreatobiliary pathology encompasses all benign and malignant disease within the pancreas and biliary tract; pancreatic cancer is currently the seventh leading cause of death worldwide accounting for approximately 466,000 deaths per annum. Cytology has been increasingly used in the physician's toolbox to provide an accurate, non-invasive and cost-effective modality for the diagnosis of pancreatobiliary lesions. The cytological appearance alone may be insufficient to establish the diagnosis and it is crucial for effective clinicopathological correlation in a multidisciplinary setting highlighting, the vital role of the pathologist to ensure effective and quality care. The advent of modern diagnostic techniques has allowed for a less invasive approach to tissue sampling which when combined with routine staining and specialised immunohistochemistry can help guide the diagnosis. The Papanicolaou Classification is comparable to the current C1-C5 system which will enable standardised reporting to help to improve communication with clinical colleagues and subsequent patient management and our article will discuss the criteria used by cytopathologists to determine the grade of both pancreatic and biliary lesions.

Identification of PI3K-AKT signaling as the dominant altered pathway in intestinal type ampullary cancers through whole-exome sequencing

Background

The genetic landscape of intestinal (INT) and pancreatobiliary (PB) type ampullary cancer (AC) has been evolving with distinct as well as overlapping molecular profiles.

Methods

We performed whole-exome sequencing in 37 cases of AC to identify the targetable molecular profiles of INT and PB tumors. Paired tumor-normal sequencing was performed on the HiSeq 2500 Illumina platform.

Results

There were 22 INT, 13 PB, and two cases of mixed differentiation of AC that exhibited a total of 1,263 somatic variants in 112 genes (2–257 variants/case) with 183 somatic deleterious variants. INT showed variations in 78 genes (1–31/case), while PB showed variations in 51 genes (1–29/case). Targetable mutations involving one or more major pathways were found in 86.5% of all ACs. Mutations in APC, CTNNB1, SMAD4, KMT2, EPHA, ERBB, and Notch genes were more frequent in INT tumors, while chromatin remodeling complex mutations were frequent in PB tumors. In the major signaling pathways, the phosphoinositide 3-kinase (PI3)/AKT and RAS/mitogen-activated protein kinase (MAPK) pathways were significantly mutated in 70% of cases (82% INT, 46% PB, p = .023), with PI3/AKT mutation being more frequent in INT and RAS/MAPK in PB tumors. Tumor mutation burden was low in both differentiation types, with 1.6/Mb in INT and 0.8/Mb in PB types (p = .217).

Conclusions

The exome data suggest that INT types are genetically more unstable than PB and involve mutations in tumor suppressors, oncogenes, transcription factors, and chromatin remodeling genes. The spectra of the genetic profiles of INT and PB types suggested primary targeting of PI3/AKT in INT and RAS/RAF and PI3/AKT pathways in PB carcinomas.

Multifocal pancreatobiliary malignancies: A diagnostic and therapeutic challenge

The synchronous presentation of multifocal pancreatobiliary tumors is a rare occurrence and can prove to be a significant diagnostic and therapeutic challenge. We describe the case of a 70-year-old female who presented with a 2-week history of jaundice, reduced appetite, and mild epigastric discomfort of insidious onset. Radiological evaluation with computed tomography and magnetic resonance imaging demonstrated features consistent with a hilar cholangiocarcinoma , also known as a Klatskin tumor, involving both the cystic duct and gallbladder neck. In addition to this, a pancreatic neoplasm with associated splenic vein occlusion and metastatic deposits in the liver and lung were identified. The patient was managed with percutaneous transhepatic external biliary drainage and stenting by interventional radiology. Cytology results from the brushings obtained from the aforementioned procedure were nondiagnostic. Core biopsies were performed of the pancreatic lesion; the histopathological results of which were in keeping with pancreatic ductal adenocarcinoma . The patient was scheduled for chemotherapy however unfortunately deteriorated clinically prior to commencement. This case highlights the diagnostic and management challenges of synchronous pancreatobiliary malignancies.

Prevalence and spectrum of pathogenic germline variants in intestinal and pancreatobiliary type of ampullary cancer

BACKGROUND

Ampullary cancer may occur as a component of hereditary cancer syndromes. Mutations in inherited cancer susceptibility genes play a therapeutic role and its knowledge in ampullary cancer is lacking.

METHODS

Thirty-seven cases of ampullary carcinoma were subjected to tumor-normal whole exome sequencing with mean coverage of 100X (blood) and 200X (tumor). Data were analyzed and correlated with intestinal and pancreatobiliary differentiation.

RESULTS

There were 22 intestinal, 13 pancreatobiliary and 2 cases of mixed differentiation. One hundred and forty-three germline variations with at least >1 pathogenic germline variants (PGVs) across 83 genes were found in 36 of 37 patients. Twelve genes (14.5 %) showed >3, 20 genes (24.1 %) showed two and 51 genes (61.4 %) showed one PGVs. Intestinal differentiation showed higher PGVs (117 variants, 73 genes) than pancreatobiliary differentiation (85 variants, 62 genes). PGVs in ERCC5, MEN1, MSH3, CHEK1, TP53, APC, FANCA, ERBB2, BRCA1, BRCA2, RTEL1, HNF1A and PTCH1 were seen in >50 % of cases. Nine genes harbored somatic second hits in 14 cases. PGVs in DNA damage-repair, homologous recombination repair, TP53 transcriptional regulation, DNA double stranded breaks, cell cycle and nucleotide excision repair genes were seen in all cases of intestinal and pancreatobiliary differentiation, while DNA mismatch repair genes were found in 81.8 % of intestinal and 84.6 % of pancreatobiliary cancers. Functional pathway analysis showed that DNA damage-repair, double stranded break repair, mismatch repair, homologous recombination repair and TP53 transcriptional regulation genes were altered in both while nucleotide-excision repair was significantly mutated in intestinal type and cell-cycle genes in pancreatobiliary type (p < 0.05).

CONCLUSION

This study reports spectrum of PGVs in intestinal and pancreatobiliary differentiation of ampullary carcinoma at higher frequency through whole exome sequencing. PGVs were most frequently found in DNA repair genes. Detecting PGVs through tumor-normal sequencing may identify therapeutically actionable and double-hit mutations that can guide towards appropriate management.

The AFSUMB Consensus Statements and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound using Sonazoid

The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

The AFSUMB Consensus Statements and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound using Sonazoid

The first edition of the guidelines for the use of ultrasound contrast agents was published in 2004, dealing with liver applications. The second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some nonliver applications. The third edition of the contrast-enhanced ultrasound (CEUS) guidelines was the joint World Federation for Ultrasound in Medicine and Biology-European Federation of Societies for Ultrasound in Medicine and Biology (WFUMB-EFSUMB) venture in conjunction with other regional US societies such as Asian Federation of Societies for Ultrasound in Medicine and Biology, resulting in a simultaneous duplicate on liver CEUS in the official journals of both WFUMB and EFSUMB in 2013. However, no guidelines were described mainly for Sonazoid due to limited clinical experience only in Japan and Korea. The new proposed consensus statements and recommendations provide general advice on the use of Sonazoid and are intended to create standard protocols for the use and administration of Sonazoid in hepatic and pancreatobiliary applications in Asian patients and to improve patient management.

Subtyping of IPMN

Intraductal papillary mucinous neoplasms (IPMNs) characteristically consist of mucin-filled dilated ducts lined with neoplastic cells forming papillae with a diverse range of morphologies and varying grades of atypia. Based on morphological characteristics and immunohistochemical reaction against mucin proteins, IPMNs are classified into four distinct subtypes: gastric, intestinal, pancreatobiliary, and oncocytic. In this chapter, histomorphological criteria and techniques of immunohistochemical staining and its evaluation for subtyping IPMNs are described.

Ampulla of Vater carcinoma: Molecular landscape and clinical implications

Ampulla of Vater is a peculiar anatomical structure, characterized by the crossroad of three distinct epithelia: Intestinal, ductal pancreatic and biliary. Adenocarcinomas arising in this area represent an opportunity to understand the comparative biology of all periampullary malignancies. These neoplasms can exhibit intestinal, pancreaticobiliary or mixed features, whereas the subclassification based on morphology and immunohistochemical features failed in demonstrating a robust prognostic reliability. In the last few years, the molecular landscape of this tumor entity has been uncovered, identifying alterations that may serve as prognostic and predictive biomarkers. In this review, the histological and genetic characteristics of ampullary carcinomas are discussed, taking into account the main clinical and therapeutic implications related to this tumor type as well.

Endoscopic Management of Pancreatobiliary Neoplasms

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are the mainstays of interventional endoscopic practice. EUS occupies a central role in the diagnosis of pancreatobiliary neoplasms and offers a platform for a wide range of direct tumor therapies. Initial steps have demonstrated the feasibility of such applications in animal models and pilot studies. Larger clinical trials and incorporation of EUS-based therapies into cooperative cancer studies might demonstrate an impact in the clinical prognosis of patients with pancreatic cancer. ERCP plays an important role in elucidating indeterminate biliary strictures and in treating patients with malignant biliary obstruction who are symptomatic or have borderline-resectable or unresectable disease. ERCP-directed ablative therapies enable neoadjuvant and palliative intervention in patients with malignant biliary obstruction, in particular perihilar cholangiocarcinoma. Additional comparative, multicenter studies are needed to better understand the safety and efficacy of endobiliary brachytherapy, photodynamic therapy, and radiofrequency ablation in patients with pancreatobiliary malignancies.

The histopathologic type predicts survival of patients with ampullary carcinoma after resection: A meta-analysis

OBJECTIVES

The results of studies on the prognostic value of histopathologic differentiation of the intestinal and pancreatobiliary types of ampullary carcinoma after resection are conflicting. A meta-analysis was undertaken to investigate this issue.

METHODS

A systematic literature search was performed to identify articles published from January 2000 to August 2016. Data were pooled for meta-analysis using Review Manager 5.3.

RESULTS

Twenty three retrospective studies involving a total of 2234 patients were identified for inclusion, of whom 1021 (45.7%) had intestinal type tumors and 899 (40.2%) had pancreaticobiliary type tumors. Patients with the pancreaticobiliary type had high rates of poor tumor differentiation (P < 0.001), lymph node metastasis (P < 0.001), vascular invasion (P < 0.001), perineural invasion (P < 0.001), and positive resection margins (P = 0.004), as compared with those with the intestinal type. The pancreaticobiliary type predicted a worse overall survival (hazard ratio [HR] 1.84, 95% CI 1.49-2.27; P < 0.001) and disease-free survival (HR 1.93, 95% CI 1.23-3.01; P = 0.004).

CONCLUSION

The histopathologic type has major impact on survival in patients with ampullary carcinoma after resection, and the pancreaticobiliary type reflects a more aggressive tumor biology and is associated with worse survival.

Probe based confocal laser endomicroscopy of the pancreatobiliary system

AIM

To review applications of confocal laser endomicroscopy (CLE) in pancreatobiliary lesions and studies that assessed training and interpretation of images.

METHODS

A computerized literature search was performed using OVID MEDLINE, EMBASE, Cochrane library, and the ISI Web of Knowledge from 1980 to October 2014. We also searched abstracts from major meetings that included the Digestive Disease Week, Canadian Digestive Disease Week and the United European Gastroenterology Week using a combination of controlled vocabulary and text words related to pCLE, confocal, endomicroscopy, probe-based confocal laser endomicroscopy, and bile duct to identify reports of trials. In addition, recursive searches and cross-referencing was performed, and manual searches of articles identified after the initial search was also completed. We included fully published articles and those in abstract form. Given the relatively recent introduction of CLE we included randomized trials and cohort studies.

RESULTS

In the evaluation of indeterminate pancreatobiliary strictures CLE with ERCP compared to ERCP alone can increase the detection of cancerous strictures with a sensitivity of (98% vs 45%) and has a negative predictive value (97% vs 69%), but decreased the specificity (67% vs 100%) and the positive predictive value (71% vs 100%) when compared to index pathology. Modifications in the classification systems in indeterminate biliary strictures have increased the specificity of pCLE from 67% to 73%. In pancreatic cystic lesions there is a need to develop similar systems to interpret and characterize lesions based on CLE images obtained. The presence of superficial vascular network predicts serous cystadenomas accurately. Also training in acquiring and interpretation of images is feasible in those without any prior knowledge in CLE in a relatively simple manner and computer-aided diagnosis software is a promising innovation.

CONCLUSION

The role of pCLE in the evaluation of pancreatobiliary disorders might be better suited for those with an intermediate and low probability.

Interventional MRI-guided local delivery of agents into swine bile duct walls using MR-compatible needle-integrated balloon catheter system

The purpose of this study was to investigate the feasibility of interventional MRI-guided local agent delivery into pig common bile duct (CBD) walls using a newly designed MR-compatible, needle-integrated balloon catheter system. We first designed a needle-integrated balloon catheter system that comprised of a 22 G MR-compatible Chiba biopsy needle and a conventional 12 mm × 2 cm balloon catheter. Under fluoroscopy guidance, a custom needle-balloon system was positioned in the target CBD via a transcholecystic access. T1-weighted MRI was used to localize and reposition the needle-balloon system in the target. A 0.5 mL mixture of motexafin gadolinium (MGd) and trypan blue dye as well as 5-fluorouracil was delivered into the CBD wall through the needle-balloon system. Post-infusion T1-weighted MRI was obtained and contrast-to-noise ratios (CNRs) of CBD walls of pre- and post-MGd-blue infusions were compared by a paired t-test. In addition, post-infusion x-ray cholangiography was achieved to evaluate the potential injuries of CBDs by the needle-balloon system. Subsequent histologic analysis was performed to correlate and confirm the imaging findings. A post-infusion cholangiogram did not show any extravasation of contrast agent, indicating no procedure-related damage to the CBDs. MRI demonstrated clear enhancement of the target bile duct walls infused with MGd-trypan blue dye with average penetration depth of 4.7 ± 1.2 mm and an average MGd perfusion length of 21 ± 1.5 mm in the bile ducts and their surrounding tissues. The average CNR of the post-infusion bile ducts was significant higher than that of the pre-infusion bile ducts (110.6 ± 22 versus 5.7 ± 2.8, p < 0.0001). Histology depicted the blue dye staining and red fluorescence of MGd through the target CBD walls, which was well correlated with the imaging findings. It is feasible to use the new MR-compatible, needle-integrated balloon catheter system for intrabiliary local agent delivery into CBD walls under MRI guidance, which may open new avenues for efficient management of pancreatobiliary malignancies using MR-guided interventional oncology.

MicroRNA profiling in periampullary carcinoma

BACKGROUND

MicroRNA expression patterns in many physiological and oncogenic processes have been established. However, the role of aberrant miRNA expression in periampullary carcinoma (PAC) has not been elucidated. We hypothesize that PAC may have differential expression of miRNAs which may differentiate the tumor histological subtypes.

METHODS

Fresh paired tumor and control samples were collected from the PAC patients undergoing Whipple's pancreaticoduodenectomy. Microarray miRNA profiling was performed utilizing tumor (n = 40) and control tissues; adjacent normal pancreas (n = 22), six each distal CBD, duodenum and ampulla. Data obtained was subjected to statistical and bioinformatic analysis. Differentially expressed miRNAs obtained were validated using qPCR in an independent set of samples.

RESULTS

Comparison of PAC tissue samples with controls revealed 29 common and differentially expressed miRNAs (20 upregulated and 9 downregulated) with a higher statistical significance (p < 0.001) and fold change (log2 FC > 1.5). A subset of 16 miRNAs (15 overexpressed and 1 underexpressed) differed in expression levels between pancreatobiliary and intestinal subtypes. Among these, miR-375, miR-31 and miR-196a expressions varied significantly between histological subtypes. Differential expression profiles of miRNAs specific to TNM staging was also observed in PAC subtypes. Target gene prediction for the differentially expressed miRNAs in PAC revealed that target genes are enriched for certain pathways. Particularly, Wnt signaling pathway genes appear to be relevant targets for most of the differentially expressed miRNAs.

CONCLUSION

Differentially expressed common miRNA signatures identified in PAC subgroups may have a role in pathogenesis of PAC and miR-375, miR-31 and miR-196a expression patterns may differentiate PAC subtypes.

Intestinal and pancreatobiliary differentiation in periampullary carcinoma: the role of immunohistochemistry

Periampullary carcinoma (PC) is classified into intestinal and pancreatobiliary subtypes using morphology and immunohistochemistry (IHC). Different combinations of markers have been used in the literature. One hundred eight PCs were classified using morphology and IHC (CDX2, mucin [MUC] 2, cytokeratin [CK] 20, CK7, CK17, and MUC1). The expression of these markers was compared with different histologic subtypes, histopathologic prognostic parameters, and patients' survival. There were 38 intestinal and 53 pancreatobiliary subtypes classified on morphology alone. CDX2 showed high sensitivity (89.5%) and specificity (100%) for intestinal type. CK20 and MUC2 showed low sensitivity (50% and 39.5%) but high specificity (86.8% and 96.2%) for intestinal type. CK7 and CK17 showed a sensitivity of 90.5% and 32% and a specificity of 21% and 89.4%, respectively, for pancreatobiliary subtype. MUC1 was 100% sensitive but 0% specific in pancreatobiliary subtype. The overall median survival in morphologic and IHC intestinal type was 45 months versus 20 months in pancreatobiliary type (P = 0.01). Intestinal and pancreatobiliary types of PC were differentiated in 84.2% of cases by morphology alone and in 87.9% cases with IHC. CDX2-positive tumors had a median survival of 44 months versus 22 months in CDX2-negative tumors (P = .03). IHC helped in reclassifying an additional 4 cases of mixed and other types. Among the panel used, CDX2 showed a high sensitivity and specificity for intestinal subtype and was an independent prognostic marker for longer survival. Thus, CDX2 may be used routinely with morphology in subtyping of PC, and a panel of markers may be used in morphologically difficult cases.