Darren D. Ballard

Risk models for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP): smoking and chronic liver disease are predictors of protection against PEP.

Objectives We investigated which variables independently associated with protection against or development of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and severity of PEP. Subsequently, we derived predictive risk models for PEP. Methods In a case-control design, 6505 patients had 8264 ERCPs, 211 patients had PEP, and 22 patients had severe PEP. We randomly selected 348 non-PEP controls. We examined 7 established- and 9 investigational variables. Results In univariate analysis, 7 variables predicted PEP: younger age, female sex, suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate-difficult cannulation (MDC), pancreatic stent placement, and lower Charlson score. Protective variables were current smoking, former drinking, diabetes, and chronic liver disease (CLD, biliary/transplant complications). Multivariate analysis identified seven independent variables for PEP, three protective (current smoking, CLD-biliary, CLD-transplant/hepatectomy complications) and 4 predictive (younger age, suspected SOD, pancreatic sphincterotomy, MDC). Pre- and post-ERCP risk models of 7 variables have a C-statistic of 0.74. Removing age (seventh variable) did not significantly affect the predictive value (C-statistic of 0.73) and reduced model complexity. Severity of PEP did not associate with any variables by multivariate analysis. Conclusions By using the newly identified protective variables with 3 predictive variables, we derived 2 risk models with a higher predictive value for PEP compared to prior studies.

Do larger periprocedural fluid volumes reduce the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis?

Objective Fluid therapy is a cornerstone of the early treatment of acute pancreatitis (AP), but data are conflicting on whether it affects disease severity. Administering greater fluid volumes (FVs) during induction of experimental AP preserves pancreatic perfusion and reduces severity but does not prevent onset of AP. We hypothesized that administering larger FV during endoscopic retrograde cholangiopancreatography (ERCP) associates with less severe post-ERCP pancreatitis (PEP). Methods In a retrospective cohort study, we identified 6505 patients who underwent 8264 ERCPs between January 1997 and March 2009; 211 of these patients developed PEP (48 mild, 141 moderate, and 22 severe). Data for FVs were available for 173 patients with PEP. Results In univariable analysis, only 1 of 16 variables was significantly associated with moderate to severe PEP—larger periprocedural FV was protective (0.94 ± 0.3 L vs 0.81 ± 0.4 L; P = 0.0129). Similarly, multivariable analysis of moderate to severe PEP identified 1 independent predictor—larger periprocedural FV was protective (odds ratio, 0.20; 95% confidence interval, 0.05–0.83). Conversely, moderate to severe disease correlated with larger FV administered after PEP diagnosis (reflecting treatment decisions). Conclusions This hypothesis-generating study suggests that administering larger periprocedural FVs is protective against moderate to severe PEP. Prospective studies on this topic are warranted.

Evaluating Adults With Idiopathic Pancreatitis for Genetic Predisposition: Higher Prevalence of Abnormal Results With Use of Complete Gene Sequencing

Objectives In adults with unexplained pancreatitis, the yield of complete gene versus select exosome sequencing on mutation detection and distinguishing clinical characteristics associated with mutations requires clarification. We sought to (1) compare frequency of mutations identified using different techniques and (2) compare clinical characteristics between adults with and without mutations. Methods This is a cohort study of adults with unexplained pancreatitis who underwent genetic testing between January 2008 and December 2012. We compare probabilities of having a positive mutation with complete gene sequencing versus alternatives and describe differences in characteristics among patients with and without mutations. Results Of the 370 patients, 67 (18%) had a genetic mutation; 24 (6%) were of high risk. Mutations were significantly more prevalent with use of complete sequencing (42%) versus other approaches (8%, P < 0.0001). Most (44/67, 66%) with a mutation had no family history. Those with high-risk mutations were more likely to have a family history of chronic pancreatitis (21% vs 4%, P = 0.002). Patients with pancreas divisum were more likely to have mutations (27% vs 14%, P = 0.0007). Conclusion Among individuals with adult-onset pancreatic disease, the probability of finding any mutation, including high risk, is significantly higher using complete gene sequencing. The impact on patients and providers requires further investigation.

Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection

AIM To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments. METHODS Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC. RESULTS Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified. CONCLUSION Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy.

Tu1802 Impact of Prior Biliary Drainage With Plastic Stents on the Performance of Self-Expanding Metal Stents in Patients Receiving Neoadjuvant Therapy for Pancreatic Cancer

Introduction: Malignant masquerade describes the scenario in which an operation is performed for what is presumed to be a malignant condition but for which final histopathology is benign. The aim of this studywas to investigate the incidence and importance ofmasquerade in a contemporary pancreatoduodenectomy (PD) series. Methods: Under IRB approval, a retrospective review of a prospectively collected database of patients at a tertiary care institution who underwent PD from 2000 to 2014 was performed. Final histopathology was compared to the final pre-operative diagnosis. The investigatory pathways of these patients were then evaluated. Results: 894 patients underwent PD during the study period and 61 had a benign final histopathology when a malignant origin was presumed. 56 (92%) had a biopsy or cytology performed with 15 showing atypia and an additional 9 suggestive of carcinoma. 24 patients had pre-malignant pathologies (IPMN, Duodenal & ampullary adenomas), and 15 with head pancreatic masses had a final diagnosis of chronic pancreatitis. The remaining 22 patients had a variety of conditions with no malignant potential. 17 of the 22 were symptomatic, the commonest being jaundice [n=13]. Suspicious radiology was present in all cases with a mass [n=16] and/or stricture [n=13], and 8 had concerning cytology. All patients with incidental lesions had endoscopic evaluation with cytological assessment. There was a single post-operative mortality. Conclusion: Despite modern imaging and endoscopic ultrasound, some patients still undergo resection for benign conditions without malignant potential. However for these patients PD is an acceptable approach when concern for malignancy remains despite thorough evaluation.