Éder Rios de Lima-Filho

Clinicopathologic Characteristics and Endoscopic Treatment of Post-traumatic Pancreatic Pseudocysts

Objective: Surgery is the treatment of choice for traumatic pseudocyst. Minimally invasive management of these collections has been used. The aim was to analyze the outcome after endoscopic treatment and the integrity of the main pancreatic duct caused by abdominal trauma. Methods: A total of 51 patients with traumatic pseudocyst who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Endoscopic retrograde pancreatography allowed characterization according to Takishima classification (1, 2, and 3), in which guided therapy was divided into transpapillary drainage (Takishima 2 and 3 without bulging), transmural (type 1), or combined (type 2 or 3 with bulging). Results: Endoscopic retrograde pancreatography was obtained in 47 (90%) of 51 patients. Drainage was transmural in 13, combined in 24, and transpapillary in 10. The success and recurrence rates of endoscopic treatment were 94% and 8%, respectively. There were 9 complications but no procedure-related deaths. Patients with penetrating trauma had more recurrences (P = 0.01) and risk for development of infection (P = 0.045) than those with blunt trauma. Conclusions: Endoscopic treatment of traumatic pancreatic collection is safe and effective and can be considered a first-choice alternative to surgical treatment. Endoscopic retrograde pancreatography and Takishima classification are useful in determining the best endoscopic approach.

Impact of endoscopic ultrasound-guided fine-needle aspiration on incidental pancreatic cysts. A prospective study

Abstract Objective. Widespread use of imaging procedures has promoted a higher identification of incidental pancreatic cysts (IPCs). However, little is known as to whether endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) could change the management strategy of patients having IPCs. This study has aimed to evaluate the management impact of EUS-FNA on IPCs. Material and methods. Patients with pancreatic cysts (PCs) who were referred to EUS-FNA were recruited prospectively. The referring physicians were questioned about the management strategy for these patients before and after EUS-FNA. The impact of EUS-FNA on management was then evaluated. Results. A total of 302 PC patients were recruited. Of these, 159 (52.6%) patients had asymptomatic IPCs. The average size was 2.3 cm (range: 0.2–7.1 cm), and 110 patients having smaller than 3 cm sized cysts. Lesions were located in the pancreatic head in 96 (61%) cases, and most patients (94%) had only a single cyst. The final diagnoses, obtained by EUS-FNA (91) and surgery (68), were 93 (58%) benign lesions, 36 (23%) cysts with malignant potential, 14 (9%) noninvasive malignancies, 10 (6%) malignant precursor lesions (PanIN), and 6 (4%) invasive malignancies. Management strategy changed significantly after EUS-FNA in 114 (71.7%) patients: 43% of the cases were referred to surgery, 44% of the patients were discharged from surveillance, and 13% of the cases were given further periodical imaging tests. Conclusion. EUS-FNA has a management impact in almost 72% of IPCs, with a major influence on the management strategy, either discharge rather than surgical resection or surgery rather than additional follow up.

Endoscopic papillectomy: The limits of the indication, technique and results

In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy (EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.

PANCREATIC SPLENOSIS MIMICKING NEUROENDOCRINE TUMORS: microhistological diagnosis by endoscopic ultrasound guided fine needle aspiration

CONTEXT Pancreatic splenosis is a benign condition which can mimic a pancreatic neoplasm. OBJECTIVE To describe the role of the endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic nodules suspicious for pancreatic splenosis. METHOD From 1997 to 2011, patients with pancreatic solid tumors suspicious for splenosis by computed tomography and/or magnetic resonance imaging were referred to EUS-FNA. Those cases with pancreatic splenosis confirmed by EUS-FNA or surgery were included. Endosonographic findings and clinicopathologic features were also analysed. RESULTS A total of 2,060 patients with pancreatic solid tumors underwent EUS-FNA. Fourteen (0.6%) cases with pancreatic splenosis were found. After applying exclusion criteria, 11 patients were selected. Most patients were male (7), young (mean age: 42 years) and asymptomatic (8). Endoscopic ultrasound imaging alone suspected pancreatic splenosis in 6 cases, and neuroendocrine tumors in 5 cases. Pancreatic splenosis was found most commonly in the tail, was round, hypoechoic, with homogeneous pattern, regular borders, and with scintigraphy negative for somatostatin receptors. The average diameter of these nodules identified by endoscopic ultrasound was 2.15 cm. Microhistology obtained by EUS-FNA confirmed the diagnosis in 9/10 patients. CONCLUSION Pancreatic splenosis can be diagnosed by EUS-FNA. Microhistology prevents unnecessary surgeries, and reassures asymptomatic patients with hypoechoic, homogeneous, and well circumscribed pancreatic nodules.

Papel atual dos métodos de imagem no diagnóstico das neoplasias císticas e sólidas do pâncreas: 1ª parte

The authors address the value of endoscopic retrograde cholangiopancreatography, ultrasonography, computed tomography, magnetic resonance imaging and endoscopic ultrasound for the diagnosis of cystic and solid neoplasms of the pancreas, demonstrating that each of them is of great importance to undoubtedly increase the diagnostic accuracy of the biliopancreatic system diseases. The best method for each of several tumors is then determined.

Current role of imaging methods in the diagnosis of cystic solid pancreas neoplasms: part II

The authors address the value of endoscopic retrograde cholangiopancreatography, ultrasonography, computed tomography, magnetic resonance imaging and endoscopic ultrasound for the diagnosis of cystic and solid neoplasms of the pancreas, demonstrating that each of them is of great importance to undoubtedly increase the diagnostic accuracy of the biliopancreatic system diseases. The best method for each of several tumors is then determined.

Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging

CONTEXT The identification of a bulging covered by normal epithelium is a common finding during an upper gastrointestinal endoscopy. OBJECTIVE To compare the endoscopic and endosonography findings in the differential diagnosis of the gastrointestinal bulging (subepithelial tumor or extrinsic compression). METHOD Patients referred by endosonography with bulging of upper gastrointestinal tract were studied retrospectively. The size, location, consistency and presumptive diagnosis were recorded at time of endoscopy and endosonography. Endosonography-guided fine-needle aspiration was proposed in case of uncertain diagnose to increase diagnostic sensitivity. RESULTS One hundred seventy-six patients (93 women) and mean age 62.5 years (10-87). One hundred fifty-three had subepithelial tumor and 23 had extrinsic compression as a final diagnosis. Endosonography had sensitivity, specificity and accuracy higher than those found by endoscopy for both diagnosis subepithelial tumor and extrinsic compression. Endoscopy and endosonography showed poor concordance (K = 0.13) for subepithelial tumor diagnosis and unsuitable agreement for diagnosis in extrinsic compression (K = 0.01). The endosonography-guided fine-needle aspiration had sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 75%, 72.4%, 80.5%, 65.6% and 74%, respectively. CONCLUSION Endoscopy has high sensitivity and low specificity for subepithelial tumor and both are low for the extrinsic compression. Endoscopy is a good tool for diagnosis of the subepithelial tumors, but not to determine the cause of an extrinsic compression. The endosonography identifies the layer from which subepithelial tumor comes, obtain histological samples, and increasing the diagnostic accuracy.

The Role of Endoscopic Ultrasound to Diagnose, Exclude or Stablish the Parenchimal Changes in Chronic Pancreatitis

CP is associated with a mortality rate of approximately 50% within 20 to 25 years after its onset (2,6). About 15 to 20% of patients die due to complications associated with attacks of CP, and most of the remaining deaths are due to trauma, malnutrition, infection or smoking (often associated with alcoholism) (2,6). Very little is known about the actual prevalence or incidence of CP, although estimates indicate an incidence of 3.5 to 4 cases per 100.000 (2,6).