Arto Saarela

Determinants of positive histologic margins and residual tumor after lumpectomy for early breast cancer : A prospective study with special reference to touch preparation cytology

Removal of the entire tumor by breast‐conserving surgery is important, but the determinants of adequate excision have not been established.

Randomized multicenter study of multiple plastic stents vs. covered self-expandable metallic stent in the treatment of biliary stricture in chronic pancreatitis

BACKGROUND AND STUDY AIMS The use of covered self-expandable metallic stents (cSEMS) in benign biliary indications is evolving. The aim of the study was to assess the safety and feasibility of cSEMS compared with multiple plastic stents in the treatment of benign biliary stricture (BBS) caused by chronic pancreatitis. PATIENTS AND METHODS This was a prospective, multicenter, randomized study of 60 patients with BBS caused by chronic pancreatitis. All patients received an initial plastic stent before randomization. At randomization, the stent was replaced either with a single cSEMS or three plastic stents. After 3 months, the position of the cSEMS was checked or another three plastic stents were added. At 6 months after randomization, all stents were removed. Clinical follow-up including abdominal ultrasound and laboratory tests were performed at 6 months and 2 years after stent removal. RESULTS Two patients dropped out of the cSEMS group before stent removal. In April 2014, the median follow-up was 40 months (range 1 - 66 months). The 2-year, stricture-free success rate was 90 % (95 % confidence interval [CI] 72 % - 97 %) in the plastic stent group and 92 % (95 %CI 70 % - 98 %) in the cSEMS group (P = 0.405). There was one late recurrence in the plastic stent group 50 months after stent removal. Stent migration occurred three times (10 %) in the plastic stent group and twice in the cSEMS group (7 %; P = 1.000). CONCLUSION A 6-month treatment with either six 10-Fr plastic stents or with one 10-mm cSEMS produced good long-term relief of biliary stricture caused by chronic pancreatitis.Study registered at ClinicalTrials.gov (NCT01085747).

Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

Abstract Background. The definition of a “difficult” cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP). Aims. To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis. Patients and methods. Prospective consecutive recording of 907 cannulations in Scandinavian centers done by experienced endoscopists. Inclusion: indication for biliary access in patients with intact papilla. Exclusion: acute non-biliary and chronic pancreatitis at time of procedure. Results. The primary cannulation succeeded in 74.9%, with median values for time 0.88 min (53 s), with two attempts and with zero pancreatic passages or injections. The overall cannulation success was 97.4% and post-ERCP pancreatitis (PEP) rate was 5.3%. The median time for all successful cannulations was 1.55 min (range 0.02–94.2). If the primary cannulation succeeded, the pancreatitis rate was 2.8%; after secondary methods, it rose to 11.5%. Procedures lasting less than 5 min had a PEP rate of 2.6% versus 11.8% in those lasting longer. With one attempt, the PEP rate was 0.6%, with two 3.1%, with three to four 6.1%, and with five and more 11.9%. With one accidental pancreatic guide-wire passage, the risk of the PEP was 3.7%, and with two passages, it was 13.1%. Conclusions. If the increasing rate of PEP is taken as defining factor, the wire-guided cannulation of a native papilla can be considered difficult after 5 min, five attempts, and two pancreatic guide-wire passages when any of those limits is exceeded.

Safety of Erlangen precut papillotomy: an analysis of 1044 consecutive ERCP examinations in a single institution.

Goals and Background There is controversy about the ideal utilization of precut papillotomy in endoscopic retrograde cholangiopancreatography examinations. Almost all reports in the literature concentrate on needle knife precut papillotomy, reporting a wide range of complications. We have used Erlangen precut papillotomy in our institution and our aim was to compare the safety of Erlangen precut papillotomy to standard free cannulation technique. The influence of precutting on the deep biliary cannulation rate was also recorded. Study Over a period of 48 months a total of 602 out of 1044 consecutive endoscopic retrograde cholangiopancreatography examinations fulfilled the inclusion criteria. Patients with an intact papilla who required biliary cannulation were screened. The cohort was divided into a nonprecut group (n=481) and a precut group (n=121). The standard technique included free biliary cannulation with a tapered-tip cannula. An Erlangen type papillotome was used for precutting. Complications, success rate of cannulation, and hyperamylasemia were recorded. Results Complication rates were similar in the 2 groups (nonprecut 7.1% vs. precut 8.3%, P=0.7). Hyperamylasemia was more common in the precut group (13.3% vs. 31.3%, P<0.001). The final deep biliary cannulation rate after precut papillotomy in cases with problematic cannulation was 98.2%. Conclusions Erlangen precut papillotomy results in a high deep biliary cannulation rate with no increased risk of complications when compared to cannulation using standard techniques.

Nonpalpable breast lesions: pathologic correlation of ultrasonographically guided fine-needle aspiration biopsy.

To evaluate the usefulness of ultrasonographically guided fine‐needle aspiration biopsy in routine clinical use, we evaluated retrospectively all of the 781 nonpalpable breast lesions operated on in the Oulu University Hospital during the period 1986 to 1993. There were 86 patients with 90 nonpalpable breast lesions, of which samples were taken by ultrasonographically guided fine‐needle aspiration biopsy. Open wire‐guided surgical biopsy was obtained in all cases for a histologic diagnosis. Two false‐negative results and one insufficient cytologic sample occurred in the 26 malignancies and one false‐positive result and two insufficient cytologic samples were found in the 73 benign breast lesions, giving sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy values of 84%, 93%, 94%, 95%, and 90%, respectively. The calculations include the insufficient samples. We conclude that ultrasonographically guided fine‐needle aspiration biopsy is a method comparable to mammographic and stereotactic fine‐needle aspiration biopsy methods.

How to cannulate? A survey of the Scandinavian Association for Digestive Endoscopy (SADE) in 141 endoscopists

Abstract Cannulation of the papilla vateri represents an enigmatic first step in endoscopic retrograde cholangiopancreaticography (ERCP). In light of falling numbers of (diagnostic) ERCP and novel techniques, e.g. short-wire system, we were interested in the approach novice and experienced endoscopist are taking; especially, what makes a papilla difficult to cannulate and how to approach this. We devised a structured online questionnaire, sent to all endoscopists registered with SADE, the Scandinavian Association for Digestive Endoscopy. A total of 141 responded. Of those, 49 were experienced ERCP-endoscopists (>900 ERCPs). The first choice of cannulation is with a sphincterotome and a preinserted wire. Both less experienced and more experienced endoscopists agreed on the criteria to describe a papilla difficult to cannulate and both would choose the needle-knife sphincterotomy (NKS) to get access to the bile duct. The less experienced used more “upward” NKS, whereas the more experienced also used the “downward” NKS technique. This survey provides us with a database allowing now for a more differentiated view on cannulation techniques, success, and outcome in terms of pancreatitis.

Cosmetic results after wire-guided biopsy of benign breast lesions

BACKGROUND There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT). STUDY DESIGN Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy. RESULTS The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT. CONCLUSIONS Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.

Mammographic and ultrasonographic findings in bilateral breast cancer: a comparative study.

Abstract. To compare the results of mammographic and US examinations in unilateral and bilateral breast cancers in routine clinical work, the files of all patients with 825 preoperative mammograms and 525 preoperative US examinations operated on for primary breast cancer in the Oulu University Hospital from 1983 through 1993 were retrospectively reviewed. The only statistically significant difference noted in the mammographic findings was the false-negative rates in unilateral, bilateral and metachronous second breast cancers (6.8, 16.3 and 23.3 %, respectively). The differences were mainly due to the lower sensitivity of mammography in the detection of palpable bilateral breast cancers. The false-negative rate of US was also significantly higher in bilateral breast cancers (23 %) than in unilateral cancers (11 %), and significantly higher for nonpalpable than palpable cancers in both the bilateral and the unilateral groups. The mammographic failure rates and the difference between these two groups were most pronounced during the early study period, which underscores the importance of experience and dedicated imaging technique. The smaller tumour size at the time of diagnosis and probably the loss of the opposite breast for comparison have contributed to the higher false-negative rates in bilateral breast cancer.

Adenoma of the papillae of Vater. Report of eleven cases.

Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily by transduodenal excision without any recurrences so far. One of these seven patients was found to have adenocarcinoma in a histological examination. Active surgery for adenoma of the papillae of Vater is recommended because of the precancerous nature of the lesion, and because malignancy cannot always be detected by endoscopic biopsies. Transduodenal excision could be recommend for patients at high operative risk, especially in cases with small adenomas and low-grade dysplasia, where histologically free resection margins can be achieved, but pancreaticoduodenectomy should still be performed on patients at low operative risk.

Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study.

Background Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla. Objective The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience. Methods An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, ‘classic appearance’; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists. Results Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58–0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59–0.72). Conclusion The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.