Andrew Bain

Pancreatic adenocarcinoma, version 2.2017: Clinical practice guidelines in Oncology

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

Role of Fluoroquinolones in the Primary Prophylaxis of Spontaneous Bacterial Peritonitis: Meta-Analysis

BACKGROUND & AIMS The use of antibiotics in the primary prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is controversial. Our purpose was to determine the beneficial effect of fluoroquinolones as compared with placebo in primary prophylaxis of SBP in high-risk patients with cirrhosis by using meta-analysis. METHODS Medline, Embase, Cochrane, and Web of Science databases were searched in all languages until August 2008 for randomized placebo-controlled studies evaluating the role of fluoroquinolones in primary prevention of SBP in patients with low protein ascites (total ascitic protein, <1.5 g/dL) and without history of SBP. Two investigators independently performed literature search and data extraction, and then another investigator independently reviewed whether the studies met prespecified criteria and rechecked data extraction. Odds ratios (Peto method) for the risk reduction with fluoroquinolones were calculated for each study and combined by using a random-effects model. RESULTS Four randomized controlled studies met predefined criteria. The odds ratios for developing first episode of SBP, serious infections, and mortality with fluoroquinolone prophylaxis (n = 194) versus placebo (n = 190) were 0.18 (95% confidence interval [CI], 0.09-0.35), 0.18 (95% CI, 0.10-0.32), and 0.60 (95% CI, 0.37-0.97), respectively. All studies were unidirectional in showing the beneficial effect of fluoroquinolone prophylaxis. We were limited by finding few studies with relatively small sample sizes. CONCLUSIONS Daily oral fluoroquinolone prophylaxis reduces the risk of development of first episode of SBP and mortality in cirrhotic patients with low total protein in the ascitic fluid. Fluoroquinolones might be advisable for the primary prophylaxis of SBP in selected high-risk patients with cirrhosis.

Pancreatic lymphoepithelial cyst

Figure 2. EUS image of pancreatic cyst. Figure 1. CT image of pancreatic cyst in tail of pancreas. A 67-year-old man presented with left upper-quadrant abdominal pain of 1 month’s duration. A CT scan showed a 3-cm cystic lesion arising from the tail of the pancreas (Fig. 1). The patient was referred to our institution for EUS (Video 1, available online at www.VideoGIE.org). On EUS, the head and body of the pancreas appeared normal. The main pancreatic duct was of normal caliber and measured 2 mm in the body of the pancreas. In the pancreatic tail, there was a 37-mm 19-mm round heterogeneous mass with internal round and hyperechoic globules (Fig. 2). EUS-guided transgastric FNA of the pancreatic tail mass was performed with a 19G needle. On gross appearance, the aspirated cyst fluid was dark brown, viscous, and opaque. The cyst fluid levels of amylase and carcinoembryonic antigen (CEA) were within normal reference range. Cytologic examination of the cyst fluid did not show malignant cells. There was acellular proteinaceous debris surrounded by a lymphocytic rim and epithelium. Fat droplets were seen within the lymphocytic rim (Fig. 3). The cyst contents under Diff-Quik and Papanicolaou staining showed anucleated cells in a concentric arrangement (Fig. 4). Because of the patient’s ongoing abdominal pain, we elected for laparoscopic removal of the pancreatic cyst. After careful dissection into the lesser sac, the cyst was visualized near the posterior wall of the stomach originating from the pancreatic tail. With a hand-assisted laparoscopic technique, the cyst was carefully dissected from the surrounding fatty tissue and pancreas and was removed en bloc. There were no postoperative adverse events, and the patient made a complete recovery. On gross description, the resected material was a brown-tan cystic structure with multiple yellow firm nodules arising from the inner part of the cyst wall (Fig. 5). Microscopic pathologic examination of the surgical specimen showed the cyst wall lined with squamous epithelium with foci of sebaceous differentiation. Abundant lymphocytes were also noted in the wall (Fig. 6). These findings were consistent with the diagnosis of lymphoepithelial cyst of the pancreas. Pancreatic lymphoepithelial cyst is a rare benign cyst seen mostly in middle-aged men (male:female ratio Z 4:1). They are mostly asymptomatic or cause nonspecific symptoms. Forty percent to 50% of these cysts are found

Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications

Purpose: Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. Methods: We detail our technique and report a unique application of this versatile approach. Results: Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. Conclusions: Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.

Endoscopic hemostasis of diverticular hemorrhage in a colonic conduit by use of an over-the-scope clip

A 64-year-old woman with a history of esophageal adenocarcinoma underwent Ivor Lewis esophagectomy. Twelve years later, she was found to have gastric adenocarcinoma, for which she underwent total gastrectomy with colonic interposition. The patient subsequently underwent Roux-en-Y surgical revision because of frequent reflux and bilious emesis. She presented with a 1-day history of hematemesis and melena and was found to be hypotensive, with acute anemia. She was not taking any antithrombotic medications. EGD revealed the esophagocolonic anastomosis to be 23 cm from the incisors. Fresh blood was seen within the colonic conduit. A diverticulum with an adherent clot was seen within the proximal colonic conduit, just distal to the anastomosis. Removal of the clot by suction and lavage resulted in brisk bleeding. Using an over-the-scope clip, we suctioned the bleeding diverticulum, and the clip was deployed with hemostasis (Fig. 1 and Video 1, available online at www.VideoGIE.org). She