Selective use of endoscopic ultrasound in the evaluation of carcinomas of the pancreatic head.

BACKGROUND: The aims of this study were to assess the role of endoscopic ultrasound (EUS) in the evaluation of adenocarcinoma of the head of the pancreas in cases of diagnostic dilemma and to determine the strength of agreement between perceived pre-operative stage as determined by computerised tomography (CT) and EUS and histopathological stage. METHODS: Patients undergoing pancreatic EUS were identified from a computerised radiology database. The strengths of agreement between the radiological and histopathological stages were determined by the weighted kappa (Kw) statistic. RESULTS: Fifty-eight patients were identified. Of 37 patients with a pancreatic head mass on prior imaging, 32 had a diagnosis of adenocarcinoma confirmed by EUS, as did 11 of 21 patients with suspicious pancreatic head lesions. Twenty-five of 43 patients were deemed to have resectable carcinomas, and 2 patients had resectable mucinous lesions. In comparing CT and EUS in the 25 patients undergoing resection, the Kw for T and N stages was 0.250 (p = 0.05) and -0.080 (p = 0.288), respectively, for CT, compared with 0.738 (p = 0.0001) and 0.606 (p = 0.0001), respectively, for EUS. CONCLUSIONS: EUS was effective in assessing the resectability of pancreatic head adenocarcinomas. Furthermore, EUS held a significant 3-fold advantage over CT with regard to T stage and an even higher significant advantage with regard to N stage.

Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection.

BACKGROUND & AIMS: The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay. METHODS: Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay. RESULTS: Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023). CONCLUSIONS: EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery.

Endoscopic ultrasound reliably identifies chronic pancreatitis when other imaging modalities have been non-diagnostic.

CONTEXT: There are classical radiological features for the diagnosis of chronic pancreatitis when utilising endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT), however, not all patients exhibit these features despite convincing clinical histories, which may result in diagnostic delay. OBJECTIVE: The aim of this study was to assess the use of endoscopic ultrasound (EUS) in the diagnosis of chronic pancreatitis when other imaging modalities had not yielded a diagnosis. METHODS: All patients undergoing pancreatic EUS between January 1996 and December 2004 were identified from the radiology computerised database. Sixteen patients with a clinical diagnosis of chronic pancreatitis (10 males, 6 females; mean age 53+/-4 years) underwent EUS after normal conventional imaging. Patients were then followed clinically until December 2007. RESULTS: Thirteen patients exhibited features of chronic pancreatitis not identified by other modalities, which included duct dilatation (n=8), calcification (n=7); parenchymal change (n=6), irregular undilated ducts (n=2), pancreatic ductal calculi (n=1), and fine calcification (n=1). Of the remaining 3 patients, a diagnosis of autoimmune pancreatitis was made in one, in another there was a pancreatic duct stricture of uncertain origin that was stented, and in only one case was no diagnosis established. All 13 patients with an EUS diagnosis of chronic pancreatitis subsequently underwent a repeat CT scan for surveillance of their disease and in all cases, the CT scans subsequently demonstrated evidence of chronic pancreatitis indicating radiological progression. No new pancreaticobiliary diagnoses were established during this period. CONCLUSIONS: EUS is a useful diagnostic tool confirming the diagnosis of chronic pancreatitis in 13 of 16 cases where histories were suspicious of chronic pancreatitis, and providing an alternative diagnosis in another two cases. EUS should be considered an important tool for diagnosis of chronic pancreatitis and should be used when cross-sectional imaging is non-diagnostic.

Does endoscopic ultrasound have anything to offer in the diagnosis of idiopathic acute pancreatitis?

OBJECTIVE: The aim of this study was to investigate the role of EUS where other investigative techniques had failed to identify the cause of biochemically proven acute pancreatitis. SETTING: All biliary EUS examinations performed between January 2000 and December 2004 were identified from the radiology computerised database. PATIENTS: Forty-two patients (25 male, 17 female; mean age: 53+/-3.2 years) with negative prior radiological investigations underwent EUS. MAIN OUTCOME MEASURES: Prior and later radiological investigations, hospital readmission, and the need for further surgical intervention were also analysed. RESULTS: EUS was normal in 17 patients (40.5%) and demonstrated signs of recent acute pancreatitis but no other aetiological factor in 8 patients (19.0%). Cholelithiasis or microlithiasis was identified in 9 patients (21.4%), combined gallstones/microlithiasis and choledocholithiasis in was seen in 6 patients (14.3%). In one patient (2.4%), calculi were seen in the common bile duct but not the gallbladder. In a further case with recurrent acute pancreatitis (2.4%), chronic pancreatitis was diagnosed on EUS. All patients with common bile duct stones underwent ERCP and sphincterotomy, and stones were universally confirmed. One patient with gallbladder calculi alone required an ERCP after developing jaundice whilst awaiting cholecystectomy. CONCLUSIONS: EUS provided additional diagnostic information in 17 of the 42 patients (40.5%). Moreover, exclusion of gallstones/microlithiais is also important as it facilitates a search for other causes of pancreatitis. In conclusion, most cases of cholelithiasis can be diagnosed with standard imaging modalities but when these fail to identify a cause, EUS has an important role to play.

Upregulation of tumour endothelial marker-8 by interleukin-1beta and its impact in IL-1beta induced angiogenesis.

Tumour endothelial marker-8 (TEM-8) has been found to be selectively upregulated in tumour-associated endothelial cells and is implicated in tumour specific angiogenesis. Specific factors, indigenous to tissues and tumours that regulate the TEM-8 mechanism in angiogenesis are not defined. We report for the first time that interleukin-1beta induces the expression of TEM-8 in endothelial cells. Human vascular endothelial cells (HECV), which strongly express IL-1beta receptor (as revealed by RT-PCR, Western blotting), increased the level of TEM-8 expression following stimulation with IL-1beta (as revealed by conventional and quantitative RT-PCR). Using a newly developed antibody to human TEM-8, we have further demonstrated that IL-1beta significantly raised the level of TEM-8 at the protein level, as revealed by Western blotting. In vitro tubule forming assay, revealed that IL-1beta significantly induced the formation of capillary-like tubules from the HECV cells, accompanied by an increase in TEM-8 expression. It is concluded that IL-1beta is a powerful regulator of the expression of TEM-8 in vascular endothelial cells. Our results suggest an important pathway through which IL-1beta regulates tumour-associated angiogenesis.