Introduction

The undetermined pancreatic cystic neoplasms represent 20-30% of the total number of pancreatic cystic lesions(PCL). The diagnostic accuracy of endoscopic ultrasound (EUS) morphology is 51%. Endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA) should be performed for differentiating between mucinous and non-mucinous pancreatic cysts when the characterization of the cyst cannot be made on the basis of non invasive imaging techniques.

Aims & Methods

Our aim was to assess the utility of the Neutrophil gelatinase-associated lipocalin(Ngal) concentration alone or combined with glucose level in cyst fluid obtained by EUS with EUS-FNA for discriminating between mucinous and non-mucinous PCL's.
This prospective study was performed between april 2018 and may 2020 at one tertiary referral hospital and included 63 patients , 30 with undetermined pancreatic cysts (group A) and the controlled group was represented by 33 patients with pancreatic pseudocysts after acute pancreatitis drained by EUS (group B). The patients from group A underwent EUS-FNA for liquid analysis and the patients from group B had liquid collection during the drainage of pseudocysts. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose and carcinoembryonic antigen(CEA) intracystic level) or on imaging during follow-up (24 month). We performed sandwich enzyme-linked immunosorbent assays (ELISA) for cystic and serum Ngal determination and measured glucose levels by a hand glucometer.

Results

The final diagnosis was pseudocyst in 33 patients, serous cystadenoma in 6, mucinous cystadenoma in 3, intraductal papillary mucinous neoplasms in 19 patients, and ductal adenocarcinoma in 2 patients. The cystic fluid analysis of these patients showed that the mean Ngal value for the serous cystic adenomas was 336ng/dl, 728ng/dl for the mucinous lesions and 1116ng/dl for the pseudocysts. The intracystic Ngal concentration (cut-off ≥ 500 and ≤ 800ng/dl) had diagnsotic sensitivity 70.8%, and specificity 92.3% for mucinous cysts. Serum Ngal concentration had no diagnostic contribution. The cystic glucose levels (cut-off ≤ 22mg/dl) had sensitivity 83.3% and specificity 82.1% for mucinous lesions. Combined glucose(cut-off ≤ 22mg/dl) and Ngal(cut-off ≥ 500 and ≤ 800ng/dl ) testing showed sensitivity of 58,3 and specificity 100% for mucinous cysts. Wheras either positive Ngal (cut-off ≥ 500 and ≤ 800ng/dl) or glucose (cut-off ≤ 22mg/dl) testing showed sensitivity 95.8% and specificity 74.4%.

Conclusion

Pancreatic cyst fluid NGAL concentration alone and combined with glucose level appeared to be useful in discriminating mucinous cysts.

References

State‑of‑the‑Art Update of Pancreatic Cysts -Andrew Canakis · Linda S. Lee2 Digestive Diseases and Sciences (2022) 67:1573–1587

Disclosure

Nothing to disclouse

Introduction

Previous observational studies reported a higher effectiveness of colonoscopy in preventing distal vs. proximal colorectal cancer (CRC) which we could not reproduce in a recently published observational study using target trial emulation (TTE). The design of the previous studies suffered from “time zero violation”, i.e. eligibility check, treatment assignment (screening vs. no screening) and start of follow-up were not synchronized.

Aims & Methods

We aimed to assess whether this “time zero violation” falsely induces a site-specific difference in the effect of colonoscopy. We used the same dataset underlying our recently published analysis (Braitmaier et al. 2022) based on German claims data (20% population coverage). We assessed the effect of screening colonoscopy in preventing distal and proximal CRC over 11 years of follow-up in 55–69-year-old persons at average CRC risk. Unlike in our recently published analysis, we used the design of previous observational studies with “time zero violation”. We compared the findings of both analyses.

Results

While in the recently published analysis using TTE, the relative risk (RR) of distal and proximal CRC in the screening colonoscopy vs. control group was similar (RR: 0.67 for distal, 0.70 for proximal), the analysis with “time zero violation” indicated a difference in site-specific performance. In this latter analysis, the RR was 0.41 for distal CRC and 0.66 for proximal CRC.

Conclusion

Our study demonstrates that “time zero violation” can substantially bias the results of observational studies. In our example, it falsely suggested an almost double preventive effect of colonoscopy in the distal vs. the proximal colon. The difference disappeared when the same data were analyzed using a TTE approach, which is known to avoid design-induced biases.

References

Braitmaier M, Schwarz S, Kollhorst B, Senore C, Didelez V, Haug U (2022) Screening colonoscopy similarly prevented distal and proximal colorectal cancer: a prospective study among 55-69-year-olds; Journal of Clinical Epidemiology; 149: 118-126

Introduction

The quality of colonoscopy is influenced by patient and operator factors. Studies investigating operator attentional fatigue on adenoma detection rate (ADR) have yielded conflicting results.

Aims & Methods

This study aims to compare ADR, polyp detection rate (PDR) and sessile serrated lesion detection rate (SSLDR) and complication rates between elective colonoscopies performed early and late in the list, across multiple operators (n>15), over 10 years, in a tertiary Brisbane (Australia) hospital.
A retrospective study was conducted on elective colonoscopies performed between 2012 and 2022 at The Prince Charles Hospital. ‘Early procedures’ are defined as procedures starting in the first hour of the first procedure starting and ‘late procedures’ are defined as procedures starting within the last hour of the last procedure starting. This pre-defined early and late procedures were used as surrogate markers for operator fatigue, accounting for a possible non-linear relationship between time and onset of fatigue, as well as the variation in number of colonoscopies performed every hour. Timing and the order of colonoscopy were used as alternative surrogates, in a secondary analysis.
Logistic regression was performed on all categorical outcome variables, and Poisson regression was modelled on continuous outcome variables, due to their non-linear distribution. Multivariate analysis included all potential confounding variables related to outcomes of interest. Statistical significance was defined as a P-value less than 0.05. Statistical analyses were performed using the SAS® statistical software (SAS Institute Inc, USA).
Exclusion included; surveillance for IBD and elective ESD.

Results

In total, 15 proceduralist (11 gastroenterologists, 4 surgeons) performed 39, 206 elective colonoscopies from 2012 to 2022. The baseline characteristics of patients, year and procedure sessions are similarly distributed between the early and late groups.
Multivariant analysis found significant associations between late procedures and lower adenoma detection rates, polyp detection rates and SSL detection rates. After adjusting for age, gender, proceduralist, year, morning or afternoon procedure, and bowel preparation quality, PDR, ADR and SDR remain 20-28% lower in late colonoscopies compared with early ones. We also found that age, gender, proceduralist, year and bowel preparation independently affected ADR in multivariant analysis. However, morning or afternoon ADRs did not significantly differ after adjusting for other variables. Proceduralist were found to be the only additional significant variable for SDR in multivariant analysis. There was no significant association between timing of procedures and major adverse events.

Conclusion

This is the largest single-centre study on operator fatigue and its effect on colonoscopy quality. Although the minimum standards for ADR was achieved, ‘late procedures’ have statistically significant lower ADR, PDR and SSLDR compared to ‘early procedures’. There was no difference in the complication rates between ‘early procedures’ and ‘late procedures’.
This study highlights the detrimental effect of fatigue in later procedures affecting the quality of colonoscopies and may be applicable in principal to other procedural based clinical work. Importantly, this may or perhaps will or is having an impact on patient safety, satisfaction, outcomes and clinical KPI’s for the operators and hospital administrators.

Disclosure

None

Introduction

Abdominal pain is the cardinal symptom of acute pancreatitis (AP), often requiring opioid therapy. We aimed to investigate the dose-response relationship between exposure to opioids and the development of moderately severe and severe AP.

Aims & Methods

This was a post-hoc analysis of the prospective PAINAP database, which recruited patients with first-time AP from 118 centres across 27 countries between April 1 and June 30, 2022. From this database, we extracted baseline patient characteristics, post-pancreatitis outcomes and information regarding the dosage of opioid treatment. The morphine-equivalent doses (MEDs) of each opioid administered were calculated based on daily doses and duration of treatment and subsequently summarized into total cumulative MEDs for each patient. Using multivariable regression analysis, we identified risk factors for developing moderately severe or severe AP.

Results

The final cohort for this post-hoc analysis consisted of 1,030 AP patients receiving various doses of opioids (51% male; median age 54 (IQR, 40-69) years). The median pain severity on admission was 7 (IQR, 6-8), and in 504 (50%) patients, the pre-admission duration of pain was more than 24 hours. Most patients (78%) had mild AP, whereas 14% and 8% of patients developed moderately severe and severe AP. On multivariable analysis, a high burden of comorbidity (CCI>2), alcohol aetiology, pre-admission pain duration >24 hours and higher pain severity on admission were independent risk factors for moderately severe or severe AP. There was a significant increase in the risk of moderately severe or severe AP, per mg MED (OR 1.00 (95% CI, 1.00-1.00), P=0.039). Accordingly, receiving >40 mg MED (compared to <10 mg MED) increased the risk of moderately severe or severe AP (OR, 3.51 (95% CI, 2.09-5.93), P<0.001).

Conclusion

The association between opioid exposure and severity of AP was dose dependent. Further studies are warranted to explore this association as this may have clinical implications for pain management in AP.