Clinical Case Summary

IgG4-related disease is an immune-mediated systemic disease characterized by the formation of pseudomasses and tissue destruction. Pancreatic involvement is the most common, followed by involvement of the salivary gland, orbit, retroperitoneum and lymph nodes.
A 76-year-old woman presents with painless jaundice. A 6cm cyst in pancreatic head is identified in pancreatic MRI (image 1), with no signs of malignancy. Endoscopic ultrasound-guided fine-needle aspiration cytology is compatible with serous cystadenoma. ERCP is performed for bile duct drainage, with unsuccessful placement of a plastic biliary stent,
and finally requiring cephalic pancreaticoduodenectomy by Whipple's technique for adequate drainage.

The histological study reveals a gastric type intraductal papillary mucinous neoplasm (IPMN), and signs of lymphoplasmacytic sclerosing pancreatitis (autoimmune pancreatitis type I) in relation to IgG4 (Image 3). Induction with 40mg prednisone is started for 2 months.
As the dosis was tapered, signs of perivascular fat infiltration were identified, in relation to retroperitoneal fibrosis (image 4), this responded to an increase of the dosis. The patient currently maintains normal serum levels of IgG4 and radiological stability with prednisone 2.5 mg/d.

Formation of pseudomasses is a common manifestation of IgG4 disease, representing a diagnostic challenge with neoplasms. An increased risk of pancreatic cancer has been described in these patients, probably in relation to the development of chronic pancreatitis in some cases.
IPMN rarely arise in the context of an autoimmune disease; identifying 9 published papers in literature, regarding 15 patients with a concomitant diagnosis of IPMN and autoimmune pancreatitis. The majority present simultaneously as in our case.
Finally, it is unknown whether IPMN can arise spontaneously from underlying autoimmune pancreatitis; or if the inflammatory changes of autoimmune pancreatitis can be secondary to IPMN.

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

Clinical Case Summary

Introduction: Locally advanced pancreatic tumors can lead to both biliary and duodenal obstruction by invasion or compression. Quality of life is severely affected if obstruction occurs: jaundice, emesis and pain can become invalidating and patients become too frail for palliative chemotherapy and are sometimes declared unfit even for derivative surgery. Recently, endoscopic techniques under EUS or ERCP guidance are being used to create biliodigestive and enteral anastomoses.
Clinical case: A 75-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma in January 2024. The tumor was declared unresectable and chemotherapy was initiated. A plastic stent was inserted into the main biliary duct (MBD) to ensure biliary drainage. In May 2024, she presented with cholangitis and emesis. EGD revealed duodenal stenosis and ERCP failed due to tumor infiltration. A combined endoscopic approach was performed: EUS-guided hepatico-gastrostomy (EHG) for biliary drainage and EUS-guided gastro-enterostomy using a lumen-apposing metal stent (LAMS). In July 2024, the plastic stent was removed, and in August 2024, two fully covered 60 x 10 mm SEMS were inserted antegrade through the EHG into the MBD to improve patency. At 11 months post-intervention, the patient returned for routine reassessment, declaring good clinical performance: she remained asymptomatic, with routine blood tests, including bilirubin levels within normal range and with all stents patent and correctly positioned (confirmed radiologically and endoscopically). The patient was able to maintain oral intake and continue chemotherapy. No late adverse events were noted.
Conclusion: This case demonstrates the long-term clinical and technical success of a staged endoscopic triple bypass for the management of complex biliary and duodenal obstruction due to unresectable pancreatic cancer. The approach was minimally invasive, well tolerated and remarkably improved the patient's quality of life.

References

1. Adler, Douglas G MD; Baron, Todd H MD, FACP. Endoscopic Palliation of Malignant Gastric Outlet Obstruction Using Self-Expanding Metal Stents: Experience in 36 Patients. American Journal of Gastroenterology 97(1):p 72-78, January 2002. | DOI: 10.1111/j.1572-0241.2002.05423.x
2. Giovannini, Marc. (2019). EUS-guided hepaticogastrostomy. Endoscopic Ultrasound. 8. 35. 10.4103/eus.eus_47_19.
3. Dumonceau, Jean-Marc & Tringali, Andrea & Blero, Daniel & Devière, J & Laugiers, R & Heresbach, D & Costamagna, Guido. (2012). Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 44. 277-98. 10.1055/s-0031-1291633.
4. Van Der Merwe, S. W., Van Wanrooij, R. L., Bronswijk, M., Everett, S., Lakhtakia, S., Rimbas, M., ... & Van Hooft, J. E. (2022). Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy, 54(02), 185-205. 10.1055/a-1717-1391

Introduction

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a promising minimally invasive technique for the management of unresectable pancreatic adenocarcinoma. Despite its potential, the practical outcomes and overall survival implications of this technique require thorough assessment in real-world settings.

Aims & Methods

This prospective study aimed to evaluate the feasibility, safety, and efficacy of EUS-RFA in patients with locally advanced or metastatic pancreatic adenocarcinoma. For the procedure, an RFA 19-g needle with an electrode active tip length of 10 mm was introduced into the tumor through the working channel of the echoendoscope. The generator settings were set at 35 W, and energy was applied from the distal to the proximal margin of the tumor until the entire lesion was treated. (video 1 EUS RFA PADC.mp4) The primary endpoints were technical success, complication rate, and overall survival.

Results

Twenty consecutive patients (58% female; average age 60 +/- 11.5 years; average tumor diameter, 37 +/- 16.7 mm) underwent EUS-RFA combined with subsequent chemotherapy. Sixteen patients (80%) were diagnosed with locally advanced adenocarcinoma, while four (20%) had metastatic disease. Technical success was achieved in 100% of the cases. The median overall survival was 15 +/- 2.2 months. No adverse events were reported. It should be noted that a patient with locally advanced adenocarcinoma downstaged after multimodal therapy and underwent surgical resection.

Conclusion

EUS-RFA is a feasible and safe treatment modality for patients with unresectable pancreatic adenocarcinoma, with high technical success and low complication rates. Future studies with larger cohorts are needed to confirm these findings and optimize treatment protocols.

Introduction

Portal vein thrombosis is a common complication of cirrhosis regardless of etiology. Medical management with anticoagulant treatment was a subject of debate with many questions about the balance between bleeding risk and therapeutic benefit. Recently, it has been proven that anticoagulant treatment improves the prognosis of liver disease and portal hypertension, without any additional bleeding risk.

Aims & Methods

The aim of our study is to identify the prognostic impact of anticoagulant treatment for portal vein thrombosis in cirrhotic patients.
It is a retrospective study including all patients followed for cirrhosis at our institution between January 2017 and August 2022. The diagnosis and monitoring of portal vein trunk recanalization were performed by Doppler ultrasound and computed tomography scan
Treatment was decided on a case-by-case basis and was dependent on the stage of liver disease, patient age, and extension of thrombus
Patients excluded: patients with portal cavernoma. upper endoscopy was systematically performed before treatment.
The prognosis improvement rate was determined by the Child-Pugh score at baseline and at completion of the study.

Results

A total of 53 patients with portal vein thrombosis were included among 285 cirrhotic patients followed during this period.
Portal vein thrombosis was diagnosed in 11.3% (n = 6).
The mean age was 54 years, with a male-to-female ratio of 0.7 (22 males/31 females).
The etiology of cirrhosis included chronic hepatitis B in 11.3% (n = 6), chronic hepatitis C in 5.6% (n = 3), primary biliary cholangitis in 3.7% (n = 2), autoimmune hepatitis in 1.8% (n = 1), Budd-Chiari syndrome in 1.8% (n = 1), Wilson's disease in 1.8% (n = 1), and idiopathic causes in 73.5% (n = 39). Before PVT diagnosis, the Child-Pugh score was classified as follows: A in 71.6% (n = 38), B in 24.5% (n = 13), and C in 3.7% (n = 2).
The main cirrhosis decompensations were bleeding related to portal hypertension in 67.9% (n = 36), ascites in 54.7% (n = 29), and hepatocellular carcinoma (HCC) in 3.7% (n = 2).
Anticoagulant treatment was indicated in 47.1% (n = 25) of cases, 48% of patients (n = 12) were treated with low molecular weight heparin (LMWH), 44% (n = 11) with direct oral anticoagulants (DOACs), and 8% (n = 2) with acenocoumarol. Among patients treated with anticoagulants, 68% (n = 17) had hemorrhagic decompensation, 56% (n = 14) had ascitic decompensation, 8% (n = 2) had hepatic encephalopathy, and 4% (n = 1) had hepatocellular carcinoma.

Conclusion

In our study, 71% of patients had a Child Pugh A score at the time of PVT diagnosis. 40% of patients maintained a stable Child score during follow-up and 28% even improved their prognostic stage.

References

https://doi.org/10.1016/j.jhep.2023.02.023
https://doi.org/10.1016/j.jhep.2023.10.002
https://doi.org/10.1016/j.jhep.2023.03.022
https://doi.org/10.1016/j.jhep.2023.05.040