Introduction

Microlithiasis and sludge have been considered the largest aetiological drivers within the cohort of idiopathic acute pancreatitis for decades. Subsuming microlithiasis and sludge-induced pancreatitis patients into the idiopathic or gallstone-induced pancreatitis cohorts has so far made adequate risk assessment regarding pancreatitis outcome impossible. It is therefore still unclear whether different therapeutic approaches are needed for microlithiasis and sludge than for gallstone-induced pancreatitis.

Aims & Methods

348 patients with acute biliary pancreatitis treated at a high-volume pancreas centre from 2005 to 2021 were stratified into a total of 7 concrement groups using the new consensus definition for microlithiasis and sludge. The gallstone-pancreatitis cohort was compared with the microlithiasis and sludge cohort and all possible combination concrement groups with regard to pancreatitis disease progression (cholestasis pattern, EUS/ERCP results).

Results

Microlithiasis and sludge-induced pancreatitis as well as combination concrement groups classified according to the revised Atlanta classification did not show a milder course than gallstone-induced pancreatitis (p = 0.63). Microlithiasis (3.6 mg/dl; mean) and sludge (2.6 mg/dl; mean) showed an increase in bilirubin on the day of admission to hospital due to pancreatitis, which was not significantly different from gallstone-induced pancreatitis (3.5 mg/dl mean, normal range < 1.2 mg/dl; p = 0.067). The highest EUS concrement detection and ERCP concrement extraction rate occurred on the day of admission and day 1, respectively. EUS detection rate (day 1): Gallstone AP 44.82 % (n = 13/29), Microlithiasis AP 46 % (n= 7/15), Sludge AP 40.7 % (n = 11/27), p = 0.98; ERCP extraction rate (admission day): Gallstone AP 39.1 % (n = 18/46), Microlithiasis AP 25 % (n = 5/20),Sludge AP 38.8 % (n = 7/18); p = 0.49).

Conclusion

Microlithiasis and sludge achieve a gallstone-equivalent cholestasis pattern and also do not differ in pancreatitis outcome from gallstone-induced acute biliary pancreatitis. In the case of EUS detection of microlithiasis and sludge in the early phase of acute pancreatitis, the concrement should be considered as a trigger rather than a cause of pancreatitis (unless another aetiology can be detected).

Clinical Case Summary

Pancreatic cystic lymphangioma is extremely rare, accounting for less than 5% of pancreatic cystic neoplasms and less than 1% of all lymphangiomas.¹
A 51-year-old female presented with complaints of recurrent abdominal pain for 4 weeks. She was previously misdiagnosed as acute pancreatitis complicated with pancreatic pseudocyst. There was no history of trauma. Dynamic MRI on the abdomen revealed a large, encysted collection at the pancreatic body suggesting a query pancreatic pseudocyst. EUS examination revealed a large cystic lesion at the body of the pancreas. The cyst was multilocular with characteristic multiple thin septa within the lesion (Figure 1). EUS-FNA with 22-G needle was done with aspiration of about 20 ml of cyst fluid, divided into two bottles, one for cytology examination and mucin stain while the second bottle for Amylase, CEA and TG levels. Aspiration fluid was serous yellowish in colour, with negative string sign. Also, a large focal lesion within the spleen was also seen.The biochemical evaluation of the aspirated cystic fluid revealed low amylase and CEA, and high TG levels. Cytopathological examination showed fairly cellular material featuring numerous predominantly small lymphocytes. There were no epithelial, atypical, or malignant cells. IHC staining was positive for CD-31 and CD2-40. Alcian blue mucin stain was negative. The diagnosis of pancreatic cystic lymphangioma was made based on EUS, cytological and biochemical examination with IHC features. Since, lymphangiomas are benign tumors without malignant potential, treatment depends on the symptoms. Lymphangioma can encroach on adjacent organs and need surgical resection. To relieve symptoms of abdominal, distal pancreatectomy and splenectomy was discussed, but patient refuse surgery. Multidisciplinary team decided a conservative management with a follow-up by dynamic MRI and EUS within 6 months.

References

1. Chen D, Feng X, Lv Z, Xu X, Ding C, Wu J. Cystic lymphangioma of pancreas: A rare case report and review of the literature. Medicine (Baltimore). 2018 Jul;97(28): e11238. doi: 10.1097/MD.0000000000011238.

Clinical Case Summary

Caudate lobe hypertrophy is a common finding in cirrhotic liver, although giant variants are rare. Nevertheless, any lesion on a cirrhotic liver warrants consideration for hepatocellular carcinoma (HCC).
This case involves a 28-year-old male patient irregularly followed up at our center for secondary biliary cirrhosis. With a history of intrahepatic bile duct paucity due to Alagille syndrome since neonatal age, he is a current smoker (10 pack-years) with no alcohol abuse. After three years lost to follow-up, the patient presented with a gradual 4-month onset of jaundice, dark urine, and upper right quadrant discomfort. Laboratory findings revealed worsening liver function tests: total bilirubin 11.5 mg/dl (vs 2.5 mg/dl), predominantly conjugated 7.6 mg/dl (vs 1.7 mg/dl), alkaline phosphatases 3.3x ULN (vs 2.6x ULN), gamma-glutamyl transferase 6.4x ULN (vs 4.5x ULN), aspartate aminotransferase 3.8x ULN (vs 1.7x ULN), alanine aminotransferase 1.5x ULN (vs 1.3x ULN).
The 4-phase CT scan revealed a dysmorphic liver with a large mass spanning segments 4, 5, 6, 7, and 8, measuring 130x100mm. The mass exhibited arterial enhancement without late phase washout and no evidence of a capsule. This mass displaced the hepatic veins and abutted the inferior vena cava and portal branches, without signs of invasion. MRI showed a similar appearance with no diffusion restriction. Initially suspected as HCC, the mass was classified as LIRADS-4. Alpha-foetoprotein level was normal. CT-guided biopsy retrieved multiple 41mm samples. Histopathological findings indicated annular fibrosis with histological cholestasis and no malignant cells. Therefore, the established diagnosis was caudate lobe hypertrophy, following a multidisciplinary team discussion and review of radiological features.
Despite this entity's rarity, biopsy seems crucial to rule out HCC, especially with abnormal vascular behavior like arterial enhancement, to avoid overtreatment.

Introduction

The mainstay of treatment of Zenker’s diverticulum is cricopharyngeal myotomy. Although flexible endoscopic septotomy is widely implemented, complete myotomy is difficult to assess resulting in recurrence rates of 11%. On the other hand, ZD peroral endoscopic myotomy allows complete myotomy visual confirmation, at the expense of procedure length and complexity. To overcome these limitations, a hybrid technique that allies FES simplicity and fastness to zPOEM efficacy is proposed: 1-septum isolation with overtube; 2-standard FES until middle of the diverticulum; 3-muscular septum isolation by zPOEM until the base of the diverticulum; 4-complete myotomy; 5-residual mucosal flaps section; 6-mucosotomy closure with TTS clips. We aim to demonstrate the feasibility, effectiveness and safety of the hybrid zPOEM technique for the treatment of ZD.

Aims & Methods

A retrospective analysis including patients with ZD treated by hybrid zPOEM procedure from April 2021 to February 2023 was made. Technical success, early clinical success (dysphagia score ≤ 1), adverse events and recurrence rates were evaluated.

Results

11 patients (male 54.5%, mean age 72.9 years) underwent hybrid zPOEM procedure for treatment of ZD (mean size 23.18mm, range 15-30mm). The procedure was technically successful in all patients, with a mean procedure time of 21.6 minutes. Early clinical success was achieved in all patients, although 1 patient maintained occasional regurgitation due to incomplete mucosal flaps section. Mean symptoms scores improved from baseline for dysphagia (1.5 vs 0), regurgitation (1.5 vs 0.1), halitosis (0.5 vs 0), cough (0.5 vs 0) and hoarseness (0.3 vs 0). During a mean follow-up time of 10 months, no recurrence was recorded. No intra- or post-procedure AE were recorded.

Conclusion

Hybrid zPOEM technique is a fast, safe and effective procedure, where, by combining classic FES and zPOEM, one can have the best of both techniques. This procedure should be considered as a first-line therapeutic option in third-space-endoscopy experienced centers.

References

Zhang LY, Nieto J, Ngamruengphong S, Repici A, Khashab MA. Zenker’s diverticulum: advancing beyond the tunnel. VideoGIE. 2021;6(12):562–7
Lupu A, Lafeuille P, Yzet C, Benech N, Jacques J, Rivory J, et al. Hybrid peroral endoscopic myotomy for large Zenker’s diverticulum. Endoscopy. 2022;54:E862–3.
Krishnan A, Ichkhanian Y, Runge TM, Khashab MA. Hybrid endoscopic approach for submucosal tunneling septum division for Zenker s diverticulum. Endoscopy. 2020;52(12):E457–8.