Introduction

​According to the International Consensus Diagnostic Criteria (ICDC), histological evaluation is crucial in diagnosing autoimmune pancreatitis (AIP). However, it is challenging to obtain pre-operatively using standard fine needle aspiration (FNA). In the last decade, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB), particularly new-generation needles with end-cutting design, has been demonstrated to outperform FNA in pancreatic solid lesions. More recently, their role in AIP definition has been evaluated with promising results. We aimed to assess the utility of EUS-FNB end-cutting needles in enhancing ICDC diagnostic levels in suspected AIP patients and in defining the specific AIP subtype.

Aims & Methods

Adult patients with suspected focal or diffuse AIP, classified as probable type 1, type 2, or NOS AIP according to ICDC, were prospectively and competitively enrolled in four different Centers. Definitive AIP, previously diagnosed AIP, and patients who had steroid administration within three months were excluded. All patients underwent EUS-FNB with a 22-gauge end-cutting needle. The capability of EUS-FNB in enhancing ICDC diagnostic level, the detection rates of level 1 or 2 of histologic criterion, the diagnostic accuracy of FNB in this setting, and the malignancy rate were calculated.

Results

A total of 52 suspected AIP were enrolled (75% male, mean age 57.9 ± 17.3), 50 with focal/segmental appearance and 2 with diffuse pancreatic involvement. The ultimate diagnosis was AIP in 39 (75%) patients (including 26 (50%) type 1 AIP, 12 (23.1%) type 2 and 1 (1.9%) type NOS) and malignancy in 7 (13.5%) (including 3 adenocarcinomas, 2 lymphomas, 1 neuroendocrine tumor and 1 metastasis). Chronic pancreatitis was diagnosed in the remaining 6 (11.5%) patients, with no recurrence or malignancy onset during a mean follow-up of 14 months (range 12-48). EUS-FNB improved the diagnostic level of AIP in 36 out of 39 (92.3%) patients with a final diagnosis of AIP, 29 (74.3%) definitive, and 7 (17.9%) probable, according to ICDC. Three patients received a final AIP diagnosis after a steroid trial (respectively, one type 1, one type 2 with subsequent IBD diagnosis, and one type NOS). The rate of level 1 in type 1 and type 2 AIP was 73.1% and 50%, respectively. The level 1 or 2 rates in type 1 and type 2 AIP were 84.6% and 91.6%, respectively. The overall diagnostic accuracy of EUS-FNB was 94.2% [95% CI 84.1–98.8]. Two mild pancreatitis (3.8%) occurred after EUS-FNB in focal type 1 AIP located in the head.

Conclusion

EUS-FNB using end-cutting needles can enhance the existing diagnostic criteria, mainly in atypical and focal presentations, ruling out malignancy and defining the specific subtype in a relevant percentage of cases with an optimal accuracy (94.2%) and good safety.

Introduction

The diagnosis of non-calcific chronic pancreatitis (CP) is challenging due to the limited accuracy of available diagnostic methods. Endoscopic ultrasound (EUS) is currently considered the most accurate method for the diagnosis of the disease, but age-related changes may affect this accuracy. In this setting, EUS-guided elastography may play a relevant role by quantifying the degree of pancreatic fibrosis, thus optimizing the diagnostic accuracy of the technique.

Aims & Methods

The aim of our study was to evaluate whether EUS-guided elastographic evaluation of the pancreas in patients with suspected CP is affected by patient age.
METHODS: Prospective comparative study of patients undergoing EUS-guided elastography for the evaluation of non-calcific CP. Procedures were performed with Fujifilm linear echoendoscopes attached to the Arietta 850 ultrasound system. The number of EUS criteria for CP according to the Rosemont classification was evaluated. The degree of pancreatic fibrosis was quantified by measuring the strain histogram (SH) and strain ratio (SR). For the evaluation of SH, an area of the pancreatic body was selected, and for the analysis of SR, the same area was selected (area A), and a soft extrapancreatic area was selected as a reference (B), with the quotient B/A being the result. Data are presented as mean ± standard deviation or median and range for quantitative variables and as percentages for categorical variables. Associations between categorical variables were tested using Fisher's exact test or chi-squared test, as appropriate. Quantitative variables were analyzed by ANOVA, and the correlation between SH and SR with Rosemont classification was analyzed by logistic regression. The Spearman test was used to assess the correlation between non-parametric variables.

Results

The study included 284 patients with a mean age of 49.8 years (range 17-85), 142 males. Normal pancreas on EUS was described in 43 patients (15.1%), indeterminate changes for CP in 110 (38.7%), and suggestive findings for CP in 131 (46.1%) according to the Rosemont classification. A statistically significant positive correlation was found between age and the number of EUS criteria according to the Rosemont classification for CP, regardless of etiology (r=0.127, p=0.03), as well as in patients without risk factors (idiopathic CP) (r=0.383, p=0.008). However, no significant correlation was observed between age and EUS elastography (neither SR nor SH) in any of the patient groups.

Conclusion

The evaluation of pancreatic fibrosis by EUS-guided elastography is not influenced by the age of the patients and is therefore accurate for the evaluation of CP.

Disclosure

Julio Iglesias-Garcia, international advisor for Fujifilm, Boston-Scientific, Viatris
Yessica Dominguez-Novoa, international advisor for Fujifilm, Viatris
Jose Lariño-Noia, international advisor for Fujifilm, Boston Scientific, Viatris
J. Enrique Domínguez, international advisor for Boston Scientific, Viatris

Introduction

IPMN are considered a possible cause of acute pancreatitis (AP) due to a transient obstruction of the pancreatic duct by mucin. IPMN-associated-AP is considered a relative indication to surgery for both, prevention of recurrent attacks of pancreatitis and for a hypothesized increased risk of cancer. The published literature is based on surgical series with significant population heterogeneity including MD-IPMN, mixed-type-IPMN and BD-IPMN. No data are available on the clinical features of this particular type of AP, on the risk of recurrent pancreatitis and pancreatic cancer in patients with BD-IPMN-associated-AP.

Aims & Methods

Results

One-hundred-thirty-five patients were included (54.8% males and 45.2% females), with mean age at the first episode of AP of 55.8 ± 12.5 years. Pancreatic necrosis was diagnosed in 15 patients (11.1%) and only 1 patient (0.7%) was admitted in Intensive Care Unit. One-hundred-two (75.6%) had recurrent pancreatitis.
The median size of the largest BD-IPMN was 8 mm (IQR 7). None had mural nodules, thickened cystic walls, or dilated main pancreatic duct ≥ 5 mm. Eighteen patients (13.3%) developed main pancreatic duct dilation ≥ 5 mm. None developed dilation of main pancreatic duct ≥ 10 mm, mural nodules, thickened cystic walls, or jaundice. At Cox unadjusted analysis no BD-IPMN-related features were associated to increased risk of recurrent pancreatitis. Surgical resection was performed in 10 patients (7.4%). None developed pancreatic cancer or signs of chronic pancreatitis during follow-up.

Conclusion

BD-IPMN-associated AP has a benign clinical course. Cystic features are not related to increased risk of recurrence. Cancer risk appears extremely low in patients with BD-IPMN-associated-AP.

Introduction

Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are frequently associated with acute (AP) or recurrent pancreatitis (RP), likely due to the mucin-induced obstruction of the main pancreatic duct (MPD). According to the 2024 Kyoto Guidelines, pancreatitis represents an indication for surgical evaluation in IPMN patients. However, pancreatic sphincterotomy (PS) may represent a less invasive alternative for patients who are unfit for surgery or as a bridge to surgery, aiming to reduce the risk of further pancreatitis episodes.

Aims & Methods

This single-center retrospective study aimed to assess the efficacy and safety of PS in patients with BD-IPMN and RP. We included 33 patients who underwent PS between 2016 and 2023, with at least 12 months of follow-up. Patients with other causes of RP or prior pancreatic surgery were excluded. The frequency of pancreatitis episodes before and after PS was compared. Clinical success was defined as complete resolution or ≥50% reduction in pancreatitis episodes. Adverse events, presence of worrisome features (WF), and progression to high-risk stigmata (HRS) were evaluated. Statistical analysis was performed using paired t-test and Fisher’s exact test, with p < 0.05 considered significant.

Results

Among the 33 patients analyzed (39.4% female, 60.6% male, mean age 59 ± 13.9 years) clinical success was achieved in 81.8% of the cases. Specifically, 72.7% of the patients experienced no further AP episodes after PS and 9.1% experienced a reduction in episode frequency, while 18.2% of patients did not respond to treatment. Adverse events occurred in 15% of patients, including: 12% with post-ERCP pancreatitis (all mild) and 3% with intra-procedural bleeding; no perforations were reported. During follow-up WF emerged in 5 patients (15%), while no cases of HRS were identified. Among the 6 non-responders, 3 underwent a second PS, with 2 achieving clinical improvement, and 3 underwent duodenocephalopancreasectomy (DCP), including 1 for a concomitant pancreatic ductal adenocarcinoma (PDAC) unrelated to IPMN progression. Notably, no cases of IPMN degeneration were observed in the series

Conclusion

Pancreatic sphincterotomy appears to be a safe and effective approach for managing recurrent pancreatitis in patients with BD-IPMN, potentially reducing the need for surgery in selected cases.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

Pancreatic cystic lesions (PCLs) are common and could vary from a simple benign cyst to a highly malignant cyst.¹ Mixed lesions with a solid part and a cystic part are very uncommon. They could be a sign of malignant transformation of a cyst.² Recently the awareness of these lesions has increased, especially with the increased incidence of asymptomatic pancreatic cysts worldwide primarily due to improved detection by different advanced imaging modalities.³Therefore, the proper diagnosis, differentiation and staging of these lesions are crucial for proper management and avoiding unnecessary treatment of benign ones and missing early treatment of the pre-malignant lesions.⁴ EUS-guided fine needle biopsy (EUS-FNB) may overcome these limitations of EUS-FNA through acquisition of core tissue samples that provide the ability to assess cyst wall architecture via histology. At this point, ESGE does not recommand use of EUS-FNB for diagnosis of cystic lesions.⁵

Aims & Methods

Aim: Based to the literature, there are few reports regarding the role of EUS-FNB replacing EUS-FNA in the diagnosis of PCL. This work aims to study the feasibility and safety of EUS-FNB 22G in diagnosis of PCLs.
Methods: Of 640 consecutive EUS-FNB 22G for different lesions between January,2019 and December,2023 at our center. 60 EUS-FNB 22G were done for the patients who underwent EUS-guided sampling of pancreatic cystic or mixed lesions diagnosed by abdominal MRI and/or CT scan. The patients were retrospectively and prospectively followed. All the solid lesions, pancreatic pseudocysts (round, non-septated lesions, presence of internal debris, recent acute pancreatitis or radiologic imaging of chronic pancreatitis) and lesions interposed vessels or main pancreatic duct are excluded from this study.Patients with history of severe hemorrhagic risk (platelet count <50,000 /Lor prothrombin activity <50%) are excluded. We statistically analyse the clinical and technical success rates, in addition to evaluate the diagnostic accuracy of EUS-FNB in differentiating benign and malignant pancreatic cystic lesions. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.

Results

A total of 60 patients (mean age 65.0 ± 12.1, 36.6% females) with 60 PCLs consecutively were referred for EUS-FNB 22G and enrolled in a prospective study. 41/60 (68.3%) lesions were mixed (cystic and tissue) and 19/60 (31.7%) lesions are cystic lesions. The mean lesion size was 32.4 ± 16.6mm. The EUS-FNB 22G procedure was technically and clinically successful in all patients (100%). The mean number of needle passes, as defined as unique transluminal needle insertions into the cystic compartment, was 1.9 ± 0.6. No immediate adverse events were developed after the procedure. In 57/60 (95.0%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. Among the 10 patients who had surgical teatment, the concordance of FNB compared to surgical pathology was noticed.

Conclusion

The diagnosis of pancreatic cystic and mixed lesions with a solid and liquid component can be achieved with fine needle biopsy using a 22-gauge needle in a safe and practicable manner. This method has a great diagnostic yield and does not increase the rate of complications.

References

1. Basturk O, Coban I, Adsay NV. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications. Arch Pathol Lab Med. 2009;133:423–438.
2.Da Silva RJ, Oliveira INF, Ribeiro TC da R, Chebli LA, Pace FH de L, Chebli JMF. A Rare Presentation of a Solid Pseudopapillary Neoplasm of the Pancreas. GE Port J Gastroenterol. mars 2022;29(2):135‑8.
3. De Jong K, Bruno MJ, Fockens P. Epidemiology, diagnosis, and management of cystic lesions of the pancreas. Gastroenterol Res Pract. 2012;2012:147465.
4. Okasha H, E Behiry M, Ramadan N, Ezzat R, Yamany A, El-Kholi S, Ahmed G. Endoscopic ultrasound-guided fine needle aspiration in diagnosis of cystic pancreatic lesions. Arab J Gastroenterol. 2019;20:86–90.
5.Polkowski M, Jenssen C, Kaye P, Carrara S, Deprez P, Gines A, et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline - March 2017. Endoscopy. oct 2017;49(10):989‑1006.

Introduction

Autoimmune pancreatitis (AIP) is a rare disease that can be diagnosed, according to the International Consensus Diagnostic Criteria (ICDC). Contrast-enhanced MRI with MRCP has now largely replaced other imaging techniques and ERCP for the assessment of ductal morphology in AIP. A number of MRI-criteria have been proposed, but due to the rarity of the disease the diagnostic imaging criteria have not yet been systematically validated. Aim of the study is to review and optimize the MR-morphologic diagnostic criteria for AIP in terms of specificity and sensitivity in the diagnosis and differential diagnosis of the pancreaticobiliary system.

Aims & Methods

We analyzed retrospectively hundred-fiftysix (n=156) high-quality MRIs: AIP n=56, chronic pancreatitis (CP) n=25, pancreatic cancer (PDAC) n=25, primary sclerosing cholangitis (PSC) n=25, Non-HPB subjects n=25. The MRI reading was conducted in a blinded fashion, using defined criteria by at least two radiological experts. The statistical analysis was performed by means of Proportion test, Chi-square test or Fisher’s exact test, One-way ANOVA and Cohen’s Kappa Statistic of the level of agreement.

Results

The level of agreement between two readers was moderate to substantial agreement (κ 0.23-0.85). Sausage-like enlargment (Reader 1: Sens 30.91%, Spec 98.98%, NPV 71.85%, accuracy 74.51%; Reader 2: Sens 26.79%, Spec 98.00%, NPV 70.50%, accuracy 72.43%), restricted diffusion (Reader 1: Sens 47.83%, Spec 89.29%, NPV 75.76%, accuracy 74.51%; Reader 2: Sens 56.86%, Spec 73.26%, NPV 74.12%, accuracy 72.30%), delayed enhancement in the venous phase (Reader 1: Sens 8.70%, Spec 83.15%, NPV 63.79%, accuracy 74.10%; Reader 2: Sens 32.61%, Spec 79.31%, NPV 69.00%, accuracy 75.19%), the icicle sign (Reader 1: Sens 10.91%, Spec 100%, NPV 66.67%, accuracy 65.30%; Reader 2: Sens 37.50%, Spec 91.00%, NPV 72.22%, accuracy 71.79%) and hyperenhancement of ductal wall (Reader 1: Sens 14.29%, Spec 96.67%, NPV 67.44%, accuracy 71.90%; Reader 2: Sens 8.51%, Spec 95.45%, NPV 66.14%, accuracy 74.10%) show a good accuracy distinguishing AIP from controls. Apparent diffusion coefficient (ADC) was significantly different between AIP, PDAC and CP (ANOVA). The area under the receiver operating characteristic curve (AUROC) was 0.85 (CI 0.73 – 0.97) and 0.68 (CI 0.51 – 0.85) respectively for CP and PDAC.

Conclusion

Our study showed that the Sausage-like enlargment, restricted diffusion, delayed enhancement in the venous phase, the icicle sign and hyperenhancement of ductal wall show a good accuracy distinguishing AIP from controls.