Single-step endoscopic ultrasound-guided multiple gateway drainage of complex walled-off necrosis with lumen apposing metal stents.

In this study we analyzed the feasibility and safety of single-step multiple transluminal gateway drainage (MTGD) for complex walled-off necrosis (WON) using lumen-apposing metal stents (LAMSs). Six patients underwent endoscopic ultrasound (EUS)-guided MTGD using two LAMSs. Technical success was 100%. The mean procedure time was 29 min. The mean number of direct endoscopic necrosectomy sessions per patient was 2. Two of six patients developed adverse events, which was bleeding in both cases and treated endoscopically and surgically, respectively. The mean hospital stay was 52.5 days. No patients had residual necrosis or WON recurrence. Although the limited number of patients, the single-step MTGD using electrocautery-LAMSs can be considered a feasible and well-tolerated treatment option for patients with complex WON. Nevertheless, larger randomized controlled studies are needed in order to confirm our data and better define the advantages of this technique.

Preoperative diagnosis of a solid pseudopapillary tumour of the pancreas by Endoscopic Ultrasound Fine Needle Biopsy: A retrospective case series.

BACKGROUND: A solid pseudopapillary tumour of the pancreas (SPTP) is a rare neoplasm. AIM: We herein present five cases of SPTP diagnosed using endoscopic ultrasound (EUS) guided fine-needle biopsy (FNB) using a needle with side fenestration (ProCore-needle). METHODS: From January 2011 to June 2012 in five patients with SPTP tissue acquisition was carried out with a 19-gauge (4 patients) or a 22-gauge (one patient) needle. RESULTS: The mean age of the patients was 30.8 years, the mean lesion size was 49mm and the most common location was the tail of the pancreas (3 cases). When the samples were evaluated macroscopically, small core fragments were observed in all cases. A preoperative diagnosis of SPTP was made in all patients on the basis of the histocytological and characteristic immunophenotypic patterns and was confirmed at final surgical histology. CONCLUSIONS: In our experience, EUS-FNB is an effective and secure method for a preoperative diagnosis of SPTP.

Very high CEA level in a large pancreatic cyst: is it a surgical indication by itself?

BACKGROUND: Pancreatic mucinous cystic lesions might develop malignancy if untreated, or could harbor malignancy at the time of the diagnosis. Many reports stated that cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. METHODS: A man with a incidental pancretic cystic lesion of 35 mm in diameter was admitted to our Department. CT and EUS did not reveal solid components, main duct was not dilated and cyst fluid CEA was very high (1445 ng/ml). RESULTS: The patient underwent a pancreatoduodenectomy and the surgical specimen showed a pseudocyst with columnar mucinous epithelium, consistent with low-grade PanIN. CONCLUSIONS: Is it possible that the mucinous epithelium of panIN was responsible for the unexpectedly high CEA value? Clinicians should be aware of the usefulness of the CEA level in cystic fluid but even a very high CEA value should not be considered by itself to be evidence of a mucinous lesion.

Endoscopic ultrasound-guided fine needle aspiration with 22- and 25-gauge needles in solid pancreatic masses: a prospective comparative study with randomisation of needle sequence.

BACKGROUND: The difference in the diagnostic accuracy of 22- versus 25-gauge needles in EUS-FNA is not clear. AIMS: To compare the rates of technical success, diagnostic accuracy and complications of EUS-FNA performed with 22-gauge and 25-gauge needles on the same solid pancreatic mass. METHODS: All patients with solid pancreatic masses evaluated from September 2007 to December 2008 were enrolled and underwent EUS-FNA with both 22- and 25-gauge needles with randomisation of needle sequence. The accuracy of the EUS-FNA was determined by comparing the cytological results with the final surgical pathological diagnoses or with the results of a clinical follow-up. A cytological score with different qualitative parameters was created, and a comparison between these parameters was carried out for each needle. RESULTS: Fifty patients with 50 pancreatic masses were recruited. Technical success was 100% and no complications occurred. Diagnostic accuracy was 94% and 86% for the 25- and 22-gauge needles, respectively. Analysis of the cytological score showed a tendency towards the 25-gauge needle, although the difference was not statistically significant. CONCLUSIONS: EUS-FNA performed with 22- or 25-gauge needles had the same diagnostic accuracy. Our study results confirm a significant trend towards a better cytological diagnosis for the 25-gauge needle.

Exocrine pancreatic function assessed by secretin cholangio-Wirsung magnetic resonance imaging.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is useful to assess exocrine pancreatic function by combining rapid imaging acquisition with the administration of secretin, a gastrointestinal hormone that stimulates the secretion of bile and pancreatic juice. However, extensive data on this method are lacking. This study aimed to determine whether MRCP with secretin administration is able to simultaneously detect alterations of both the pancreatic ducts and exocrine pancreatic function. METHODS: All subjects older than 18 years who underwent magnetic resonance imaging (MRI) and cholangio-Wirsung magnetic resonance imaging (CWMRI) for suspicion of benign or malignant pancreatic diseases from January 2006 to December 2006 were enrolled in the study. MRI and CWMRI were carried out using a dedicated apparatus. RESULTS: Eighty-seven patients (46 males, 41 females, mean age 59.7+/-14.6, range 27-87 years) were enrolled. Of the 87 patients, 39 had a normal pancreas on imaging, 20 had an intrapapillary mucinous tumor (IPMT), and the rest had chronic pancreatitis (7), serous cystadenoma (6), a previous attack of acute biliary pancreatitis (5), congenital ductal abnormalities (5), mucinous cystadenoma (3), previous pancreatic head resection for autoimmune pancreatitis (1), or cholangiocarcinoma (1). Morphologically, we found two pseudocysts (one of the 7 patients with chronic pancreatitis, and one of the 5 patients after an attack of acute pancreatitis; the latter pseudocyst communicated with the main pancreatic duct). Calcifications were found in 3 of the 7 patients with chronic pancreatitis. All patients with IPMT and mucinous cystadenoma and 3 patients with serous cystadenoma were histologically confirmed. The remaining patients were followed up adequately to confirm the diagnosis by imaging. According to the Matos criteria, 73 patients (83.9%) were of grade 3, 8 grade 2, 4 grade 1, and 2 grade 0. The only pancreatic diseases which impaired the exocrine pancreatic secretion stimulated by secretin were chronic pancreatitis (57.1% of the patients, grade 0-1) and the IPMT mixed type in 2 of the 4 patients was grade 1. CONCLUSION: Secretin MRCP is a useful technique to simultaneously detect the presence of alterations of the pancreatic ducts and exocrine pancreatic function.

The imaging of pancreatic exocrine solid tumors: the role of computed tomography and positron emission tomography.

The only potentially radical treatment for pancreatic cancer is the removal of the tumor which can be performed by total or subtotal surgical resection of the pancreas; this is possible in the early stages of the disease when the tumor is confined to the pancreatic gland without metastasis to the liver, lymph nodes and/or the peritoneum, or involvement of the vascular system such as the celiac trunk and its branches and the superior mesenteric artery. In this paper, we describe the accuracy of computed tomography and positron emission tomography in the diagnosis of exocrine pancreatic cancer.