Claudio De Angelis

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms.

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

Preliminary experience with a new cytology brush in EUS-guided FNA

BACKGROUNDnDespite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published.nnnOBJECTIVEnTo assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion.nnnDESIGNnCase series.nnnSETTINGnTertiary care university hospital (Molinette Hospital, Turin, Italy).nnnPATIENTSnThirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled.nnnINTERVENTIONSnThe material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists.nnnMAIN OUTCOME MEASUREMENTSnAdequacy of the sample and sensitivity and specificity of the EchoBrush method.nnnRESULTSnAdequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure.nnnLIMITATIONnPreliminary study.nnnCONCLUSIONSnThis report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

Insulated-tip knife endoscopic mucosal resection of large colorectal polyps unsuitable for standard polypectomy

OBJECTIVES:Endoscopic mucosal resection (EMR) has been shown to be safe and effective. En bloc resection is often not achieved using conventional EMR. Insulated-tip knife (It-knife) EMR has been recently proposed for early gastric cancer dissection and removal. This study was conducted to evaluate the safety and efficacy in obtaining en bloc resection with It-knife EMR of large colonic lesions not resectable with standard endoscopic techniques.METHODS:A total of 29 patients (19 men, 10 women, mean age 67.5 yr, range 44–88) were included in the study. Lesions were considered not suitable for standard polypectomy because of large diameter (>3cm), morphology, and/or position. Lesions were located in the rectum (N = 11), sigmoid: (N = 10), descending: (N = 4), transverse: (N = 2), and hepatic flexure (N = 2). After saline injection, circumferential incision and dissection of the lesions were attempted with the aim of achieving en bloc resection.RESULTS:En bloc resection was achieved in only 55.1% of the lesions (16 out of 29 patients). In the remaining cases, resection was completed with a piecemeal technique. The median size of the en bloc resected specimen was 3 × 3.4 cm. Complications occurred in four patients (13.7%). At histopathology, 13 patients had low-grade dysplasia, 15 high-grade dysplasia. One patient had a tumor invading the submucosa and was submitted to surgery.CONCLUSIONS:It-knife EMR is a promising technique for attempting en bloc resection of large colonic polyps. Adequate training and caution are required because it can be associated with a higher complication rate than with other EMR modalities.

Narrow band imaging vs. high definition colonoscopy for detection of colorectal adenomas in patients with positive faecal occult blood test: A randomised trial

BACKGROUNDnThe impact of narrow band imaging in improving the adenoma detection rate in a screening scenario is still unclear.nnnAIMnTo evaluate whether narrow band imaging compared with high definition white light colonoscopy can enhance the adenoma detection rate during screening colonoscopy.nnnMETHODSnConsecutive patients presenting for screening colonoscopy were included into this study and were randomly assigned to the narrow band imaging group (Group 1) or standard colonoscopy group (Group 2). Primary end point was the adenoma detection rate and secondary aim was the detection rate of advanced adenomas.nnnRESULTSnOverall, 117 patients were allocated to Group 1 and 120 to Group 2. Both the adenoma detection rate and the detection rate of advanced adenomas were not significantly different between the two groups (respectively, 52.1% vs. 55%, RR=0.95, 95% CI 0.75-1.20; 32.5% vs. 44.2%, RR=0.74, 95% CI 0.53-1.02). No significant difference between the proportions of polypoid and flat adenomas was found. Male gender, no prior history of screening, and endoscopists adenoma detection rate were independent predictive factors of higher advanced adenoma detection rate.nnnCONCLUSIONSnIn a screening scenario, narrow band imaging did not improve the adenoma nor advanced adenoma detection rates compared to high definition white light colonoscopy.

Antiplatelet and anticoagulant drugs management before gastrointestinal endoscopy: Do clinicians adhere to current guidelines?

BACKGROUNDnManaging antiplatelet and anticoagulant drugs before endoscopy may be challenging.nnnAIMSnTo assess whether the pre-endoscopic management of antiplatelet/anticoagulant drugs is adherent to current guidelines and the influence of patients characteristics, referring physicians specialty, type of endoscopic procedure and therapeutic regimen on adherence.nnnMETHODSnTwo hundred and twenty patients taking aspirin, thienopyridines or warfarin and scheduled for upper endoscopy (± biopsies), variceal band ligation, colonoscopy (± biopsies or polypectomy), were prospectively analyzed.nnnRESULTSnIn 109 patients (49.5%) the management of antiplatelet/anticoagulant drugs was thoroughly compliant with guidelines. Neither demographic characteristics, nor in/outpatient status, nor type of endoscopic procedure, nor physicians specialty influenced the adherence but the therapeutic regimen had a significant impact (p < 0.0001) as compliance was less likely in patients on warfarin. Unwarranted drugs withholding was more frequent before colonoscopy than upper endoscopy (p = 0.0001). Warfarin was stopped longer than recommended more frequently than aspirin (p = 0.009). The International Normalized Ratio was properly checked before endoscopy in 47.7% of patients. Among the 55 patients who withheld warfarin, the decision about bridging to low molecular weight heparin was appropriate in 21 (38.2%).nnnCONCLUSIONSnCompliance with guidelines is low especially in the management of warfarin, both among gastroenterologists and other physicians.

ENDOSCOPIC ULTRASOUND FINE‐NEEDLE ASPIRATION IN THE DIAGNOSIS OF INTRAPANCREATIC ACCESSORY SPLEEN

Intrapancreatic accessory spleens represent a potential pitfall in the diagnosis of pancreatic lesions by mimicking pancreatic neoplasms, in particular, neuroendocrine tumors. We report two cases of intrapancreatic accessory spleen discovered in patients with a previous history of neuroendocrine tumors. Case 1. A 39-year-old woman with a history of welldifferentiated pancreatic neuroendocrine tumor with liver metastases underwent follow-up endoscopic ultrasound (EUS) (Olympus GF-UCT140AL5; Olympus America, Melville, NY, USA) revealing a well-defined, homogeneous, hypoechoic lesion in the tail (Ø13 mm), suggesting a neuroendocrine localization; echo-Doppler showed arterial and venous supply. EUS-fine-needle aspiration (FNA) was carried out with a 22-G needle (Wilson-Cook, WinstonSalem, NC, USA), (Fig. 1). A dedicated cytopathologist carried out a rapid on-site evaluation (ROSE): two slides were smeared and remaining material preserved for cellblock preparation. Smears showed tangles of small blood vessels and a population of heterogeneous lymphocytes, intermixed with neutrophils, histiocytes and plasma cells (Fig. 2). Flow cytometry showed a polyclonal B and T cell population. Immunocytochemistry for cytokeratin AE1/AE3 on cell-block sections was negative.These findings were diagnostic for accessory spleen. Case 2. A 71-year-old man with a diagnosis of a welldifferentiated, somatostatin-producing neuroendocrine tumor underwent a pancreasectomy plus splenectomy in 2007. Follow-up EUS revealed a mass of 2 cm in the pancreatic head, hypo-isoechoic with smooth margins. EUS-FNA was carried out and ROSE smears showed mostly lymphocytes interspersed with other inflammatory cells. Cell-block sections showed characteristic features of both white and red pulp (lymphoid tissue with traversing vascular structures, lined by elongated, flat endothelial cells with typical beanshaped nuclei having a longitudinal cleft) and immunocytochemistry confirmed the previous findings: AE1/AE3, chromogranin and synaptophysin were CD68 KP-1 and CD8 stained the sinus endothelial lining cells, resulting in a diagnosis for accessory spleen. We confirm that EUS-FNA is a safe and sensitive test that allows an accurate diagnosis of intrapancreatic accessory spleen, ruling out neuroendocrine tumor and avoiding unnecessary surgery.

Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of pelvic metastasis of hepatocellular carcinoma: case report and review of literature.

Hepatocellular carcinoma (HCC) is the most common primary neoplasm of the liver. It shows a propensity to directly invade the portal and hepatic veins, but it also spreads by lymphatic and hematogenous routes. The most common extrahepatic metastatic sites of HCC are the lung, regional and distant lymph nodes, adrenal gland, and bone. More rarely, HCC can metastasize to the peritoneum, brain, rectum, heart, and ovary. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are very useful in identifying HCC metastases, but the procurement of a tissue sample for histological confirmation may be very challenging, especially when a suspected lesion is found in an unusual site. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has become widely accepted as a useful technique to obtain tissue samples from lesions of gastrointestinal tract and adjacent structures, including the liver, pancreas, mediastinum, abdomen, and pelvis. We present the first case in the literature of EUS-FNA diagnosis of HCC metastasizing close to the rectal wall.

5. Imaging techniques in diagnostic approaches

Despite the considerable technological advances in imaging modalities which have occurred over the last years, EUS remains one of the most reliable and accurate technique for the study of gastroenteropancreatic neuroendocrine tumors. More specifically, EUS can detect very small lesions, assess the local extent and lymph node involvement and biopsy the lesion for cytophatological confirmation (EUS-FNA). In addition, nuclear medicine imaging has a relevant role in the evaluation of NET. However, its performance depends on series of patient-specific features (lesion size and uptake, depth and other anatomic features; metabolic activity, receptor expression, affinity and vacancy, tissue specificity) and technical features (choice of tracer, administered dose, and physical half-life; instrument sensitivity, acquisition technique, reader experience). In particular, current data show that PET/CT has greater intrinsic resolution and sensitivity than SPECT or SPECT/CT images resulting in improved tumor detection. However, the PET tracer of choice has not yet been identified. 18F-FDG has proved to be useful as indicator of tumor aggressiveness rather than detection of extent of disease, and 68Ga-DOTA-TOC has demonstrated good results in clinical trials. 11C-5HTP has performed well in limited trials, but the 20-min half life of 11C precludes widespread availability. Better information concerning biodistribution and further comparative data of these agent in larger clinical trials are warranted.