Introduction

Differential diagnosis of solid pancreatic tumours (SPT) is a clinical challenge. Development of advanced imaging techniques associated with EUS, such as elastography and contrast enhancement, has been a step forward in this context. EUS-guided detective flow imaging (DFI) is a very recent technology allowing the evaluation of microvascularization and low-velocity blood flow without the need of contrast agents.

Aims & Methods

Aim of our study was to evaluate the findings obtained by EUS-DFI in SPT and compare them with contrast enhanced harmonic EUS (CEH-EUS).
Methods: A prospective, single-centre, observational study in patients who underwent EUS for the evaluation of SPT was designed. Procedures were performed with a linear echoendoscope (Fujifilm 740UT) attached to the ultrasound system Arietta 850. Lesions were characterized according to the vascularization pattern (hypervascular, isovascular and hypovascular) described with both methods. Final diagnosis was based on histology after EUS-guided biopsy. Data area shown as mean ± SD and percentage.

Results

44 patients were included (mean age 67 years, range 24-88, 23 males). Mean tumour size was 26.1 ± 15.7 mm. Fourteen (31.8%) lesions were located in the head of the pancreas, 19 (43.2%) in the body, 9 (20.5%) in the tail and 2 (4.5%) in the uncinate process. Final diagnosis was adenocarcinoma in 24 patients (54.5%), neuroendocrine tumour in 13 (29.5%), inflammatory mass in 3 (6.8%), autoimmune pancreatitis in 1 (2.3%), pancreatic necrosis in 1 (2.3%), accessory spleen in 1 (2.3%) and lipoma in 1 (2.3%). Agreement regarding the vascular pattern of SPT between CEH-EUS and EUS-DFI was reached in 97.7% of the cases. All adenocarcinomas were hypovascular, inflammatory masses and autoimmune pancreatitis isovascular, pancreatic necrosis avascular, and accessory spleen and lipoma hypervascular at both CEH-EUS and EUS-DFI. All 13 neuroendocrine tumours were hypervascular at CEH-EUS, 12 of them (90%) at EUS-DFI.

Conclusion

EUS-DFI allows evaluating the microvascular pattern of SPT with a similar accuracy than CEH-EUS, but without the need of using contrast agents.

Disclosure

Julio Iglesias-Garcia. Advisor Pentax, FujiFilm, Mediglobe

Introduction

Paraduodenal pancreatitis (PP) is a particular form of chronic pancreatitis that affects an area, defined by some authors as "groove", between the head of the pancreas, the duodenum and the main biliary tract. [1] The two forms of PP, the cystic and the “solid” form, [2] may extend to the adjacent pancreatic tissue and the entire main pancreatic duct, causing chronic obstructive pancreatitis ("diffuse" form), leading to heterogeneous clinical presentations.[3,4] Pathogenesis and natural history is still unclear, even if it has been linked to exogenous factors, especially alcohol and smoking, and the treatment include both medical therapy and surgery [5].

Aims & Methods

We performed a multicentre retrospective observational study to explore the burden of the disease, and its evolution towards exocrine pancreatic insufficiency(EPI) considering also the risk of neoplastic evolution. We collected data from both academic and non-academic Italian centers. All patients with diagnosis of PP were included in the registry. Data were extracted at the time of diagnosis and during follow-up. Univariate and multivariate analysis were performed to explore the relations between variables and outcomes of interest.

Results

208 patients(87.5% male) from 16 centres were collected into our national registry. Mean age at diagnosis was 51(± 11) years and mean time from clinical presentation to diagnosis was 18(±29) months. 88.4% had history of alcohol abuse and 89% of smoking. 36 patients(17.9%) had diabetes at diagnosis, while 80 patients (41.5%) had chronic pancreatitis. Clinical presentation included abdominal pain(89.1%), jaundice(18.5%), nausea(47.1%) and vomiting(32.6%). Initial laboratory tests showed a mean increase of bilirubin of 1.62(±1.7) times upper limit of normal(ULN), Amylase 2.9(±2.5) times ULN, Lipase 3.2(±3.1) times ULN. 6(3%) patients developed pancreatic cancer after a mean time of 10.3(±10.8) months from PP diagnosis. 49 patients(23.6%) had EPI at diagnosis , while further 49 patients developed it during follow up. Among patients with EPI at diagnosis, 19(38.8%) recovered with no more signs of EPI at the last follow up. Preliminary analyses showed that EPI at diagnosis was associated to EPI at the last follow up(OR 2.6, p=0.012). Mean time to develop EPI was 17.1(±23.5) months. Conservative treatment was the treatment of choice in 54.3% cases, surgery in 17.3% and endoscopic therapy in 16.35% cases. Over a median follow-up of 36 (range, 1-168) months, mortality was 4.8%.

Conclusion

Paraduodenal pancreatitis is an uncommon disease, mainly diagnosed in male patients with history of alcohol and smoking. Moreover, conservative strategy was the treatment of choice in our cohort of patients.

References

1. Adsay NV and G. Zamboni, Paraduodenal pancreatitis: a clinico-pathologically distinct entity unifying "cystic dystrophy of heterotopic pancreas", "para-duodenal wall cyst", and "groove pancreatitis". Semin Diagn Pathol 2004;21(4):247-54.
2. de Pretis N, Capuano F, Amodio A, Pellicciari M, Casetti L, Manfredi R, Zamboni G, Capelli P, Negrelli R, Campagnola P, Fuini A, Gabbrielli A, Bassi C, Frulloni L. Clinical and Morphological Features of Paraduodenal Pancreatitis: An Italian Experience With 120 Patients. Pancreas 2017;46(4):489-495.
3. Pezzilli R, Santini D, Calculli L, Casadei R, Morselli-Labate AM, Imbrogno A, Fabbri D, Taffurelli G, Ricci C, Corinaldesi R. Cystic dystrophy of the duodenal wall is not always associated with chronic pancreatitis. World J Gastroenterol 2011;17(39):4349-64.
4. López-Muñoz P, Lorenzo-Zúñiga V, Alonso-Lázaro N, et al. Endoscopic findings of paraduodenal or groove pancreatitis. Endoscopy. 2022;54(12):E735-E736. doi:10.1055/a-1773-0499
5. Balduzzi A, Marchegiani G, Andrianello S, Romeo F, Amodio A, De Pretis N, Zamboni G, Malleo G, Frulloni L, Salvia R, Bassi C. Pancreaticoduodenectomy for paraduodenal pancreatitis is associated with a higher incidence of diabetes but a similar quality of life and pain control when compared to medical treatment. Pancreatology 2020;20(2):193-198.

Clinical Case Summary

A 66-year-old patient underwent cephalic pancreaticoduodenectomy on 05/2021 for moderately differentiated adenocarcinoma of the distal bile duct (R1 pT3 pN1). He underwent 8 cycles of adjuvant chemoradiotherapy with Capecitabine, which ended on 12/2021. On 09/2022, locoregional recurrence was detected and the disease was considered unresectable. At this time, he started systemic therapy with Cisplatin+Gemcitabine+Durvalumab (TOAZ trial 1). Prior to the beginning of the third cycle, the patient began to suffer from food intolerance with vomiting. A CT scan showed locoregional progression of the disease with extension to the stomach and infiltration of the gastro-jejunal anastomosis. In the endoscopic comparison, the anastomotic stenosis was confirmed, only transposable with the pediatric gastroscope, leaving the efferent loop permeable. Given the unequivocal progression of the disease, an assumed palliative strategy and, in line with this decision, a minimally invasive – endoscopic – approach was chosen to protect the gastric outlet tract. Once the efferent loop has been isolated, a nitinol guidewire was advanced under direct vision through which a metal prosthesis with luminal apposition (Spaxus®) 16x20 mm was submitted by backload, released simultaneously under control under fluoroscopic control and endoscopic vision. At the end of the procedure, luminal patency was confirmed with contrast injection. One week after stent placement, the patient continues to tolerate the oral diet, was discharged and will be reassessed in a Medical Oncology consultation with the aim of starting second-line chemotherapy (FOLFOX).
Locoregional recurrence after Whipple’s procedure is high.Lumen-apposing metal stents, originally designed for the management of pancreatic fluid collections, have been shown to be option for gastrointestinal strictures due to their anti-migratory design. This report shows its application in cases of short strictures requiring preventive migration measures.

Introduction

Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients’ lives and medical resources. Endoscopic ultrasound (EUS)-ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS-ablation on PCL in terms of complete or partial response and safety.

Aims & Methods

A systematic search in Medline, Cochrane and Scopus databases was performed until April 2023 for studies assessing the performance of the various EUS-ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% Confidence Intervals (95%CI).

Results

Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS-ablation was achieved in 44% (95%CI: 31-57; 352/767; I2=93.7%), and the respective partial response rate was 30% (95%CI:20-39; 206/767; I2=86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I2=87.2%) of cases, rated as mild in 10% [(95%CI: 5-15); 128/840; I2=86.7%]; and severe in 4% (95%CI: 3-5; 36/840; I2=0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I2=42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I2= 0%) for lauromacrogol, 32% (95%CI: 27-36; I2=88.4%) for ethanol and 13% (95%CI: 4-22; I2=95.8%) for RFA. Considering adverse events, the ethanol-based sub-group rated the highest percentage [16% (95%CI: 13-20; I2:91.0%)].

Conclusion

EUS-ablation of pancreatic cysts provides acceptable rates of complete resolution and low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

Disclosure

Nothing to declare