John M. DeWitt

American College of Gastroenterology guideline: management of acute pancreatitis.

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12–24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

Comparison of Endoscopic Ultrasonography and Multidetector Computed Tomography for Detecting and Staging Pancreatic Cancer

Context Clinicians often use multidetector computed tomography or endoscopic ultrasonography to detect and stage pancreatic cancer. Contribution This prospective study found that, among 80 adults with proven pancreatic cancer, the sensitivity of multidetector computed tomography and endoscopic ultrasonography for detecting a pancreatic mass was 86% (CI, 77% to 93%) and 98% (CI, 91% to 100%), respectively. Among 53 patients undergoing surgery, endoscopic ultrasonography was more accurate for staging local tumor spread, but both tests showed similar accuracy for nodal staging and detecting resectability. Cautions Optimal strategies to detect and stage pancreatic cancer may vary across sites depending on the expertise of radiologists and endosonographers. The Editors In the United States for the year 2003, it was estimated that pancreatic cancer would be diagnosed in approximately 30700 patients and contribute to 30000 deaths (1). Complete surgical removal with negative histologic margins (R0 resection) is an independent predictor of postoperative survival (2-4) and remains the only potential curative treatment for pancreatic cancer. At surgical exploration, however, only 5% to 25% of the tumors are amenable to resection (5-8). Therefore, the principle goal of preoperative evaluation is to identify patients with potentially resectable disease while avoiding surgical exploration in those with unresectable disease. There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer. Because of widespread availability, helical computed tomography (CT) is usually the initial study for this indication (9, 10). Dual-phase helical CT, during which postinjection contrast image acquisition is obtained in both the pancreatic (arterial) and portal venous phases, has improved detection rate and assessment of resectability in patients with suspected pancreatic cancer (11, 12). Current state-of-the-art CT imaging uses a multiple-row detector with narrow detector collimation, wide x-ray beam, and rapid table translation; these features offer faster acquisition and thinner image slices compared with single-detector CT (13-15). Whether multidetector CT offers improved detection and staging of pancreatic cancer, however, is unknown. Endoscopic ultrasonography has been shown to be superior to conventional CT for the detection (16-20) and staging (19, 20) of pancreatic cancer. When compared with helical CT, however, endoscopic ultrasonography is reported to be either equivalent for detection (21, 22) or superior for detection or staging (23-25). To date, no comparative studies of multidetector CT with other imaging tests, including endoscopic ultrasonography, for suspected pancreatic cancer have been performed. Therefore, we conducted a prospective trial to compare endoscopic ultrasonography and multidetector CT for the detection, staging, and resectability of suspected locoregional pancreatic cancer. Methods Patients The institutional review board at Indiana University Medical Center approved this study, and all patients signed written informed consent. Eligible patients were referred to our hospital with clinically suspected or recently diagnosed solid or cystic pancreatic cancer within the previous 8 weeks. The referral base for our hospital consists of gastroenterologists and surgeons from Indiana and the surrounding contiguous states. Patients were eligible only if they agreed to undergo endoscopic ultrasonography, CT, and surgery (if necessary) at our institution. Patients were excluded if they had previously undergone endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography at our institution for suspected pancreatic cancer; declined or remained undecided about potential surgical intervention; were referred to our institution by surgeons outside our hospital system. Patients were also excluded if they were pregnant, were incarcerated, could not independently provide informed consent, or were considered high surgical risk (American Society of Anesthesiology class III to V). In addition, we excluded patients with known or suspected periampullary masses, cholangiocarcinomas, or cancer with suspected locally advanced arterial (superior mesenteric, hepatic, or celiac) involvement or metastatic disease (ascites, suspicious liver or pulmonary lesions, distant enlarged lymph nodes) detected by previous imaging studies. Patients with suspected nonocclusive involvement of the superior mesenteric vein or portal vein were considered eligible for enrollment. Study Design This was a prospective, single-center, observational study. All enrolled patients had to respond to an initial health and medical questionnaire, which was followed by same-day endoscopic ultrasonography. Computed tomography was performed within 1 week. Within 3 weeks after CT, a surgeon examined the patient and reviewed the results of endoscopic ultrasonography and CT to determine eligibility for potential resection. After surgery or the decision to pursue nonoperative management, we telephoned patients to assess quality of life at 1 month, 3 months, and every 6 months until death or until 24 months if clinical disease remained stable. Endoscopic Ultrasonography Technique Conscious sedation was performed with various combinations of intravenously administered propofol, meperidine, fentanyl, or midazolam. Initially, we examined all patients with a radial echoendoscope (Olympus GF-UM130 [Olympus America Inc., Melville, New York]). We then examined patients with a linear echoendoscope (using either Pentax FG-36UX [Pentax Precision Instruments, Orangeburg, New York] or Olympus GF-UC140P [Olympus America Inc.]). Unless cancer had been definitively confirmed previously, endoscopic ultrasonographyguided fine-needle aspiration was performed with a 22-gauge needle (Wilson-Cook Medical Inc., Winston-Salem, North Carolina) in all patients, when applicable. A cytotechnologist or cytopathologist was on-site for preliminary interpretations of all aspirations. One of 3 experienced gastroenterologists, each of whom had performed at least 1000 pancreatic examinations, performed all procedures. The operator was not blinded to previous radiographic data. Recorded information included the presence or absence, size, echocharacteristics, location, or locoregional extension of any visualized pancreatic mass, lymph nodes, or distant metastases. Lymph nodes that were not accessible to endoscopic ultrasonographyguided fine-needle aspiration were considered malignant if 3 or more of the following criteria were present: diffuse hypoechoic echogenicity, short-axis diameter of 5 mm or greater, well-defined borders, round shape, or location within 5 mm of the tumor. Well-defined hypoechoic or hyperechoic lesions within the liver with a short-axis diameter of 10 mm or greater and not accessible to fine-needle aspiration were defined as metastases. We considered vascular involvement by the tumor to be present if any 1 of the following were noted: loss of the normal hyperechoic interface between tumor and vessel for at least 5 mm (adherence), irregular tumor and vessel interface, tumor within vessel lumen (invasion), vessel encasement, and perigastric or periduodenal collaterals with associated venous occlusion. Immediately after the examination, any visualized mass was designated by the endosonographer as surgically resectable or unresectable and assigned a tumor, node, metastasis (TNM) staging according to the 1997 American Joint Committee on Cancer (AJCC) classification (Appendix Table) for staging of pancreatic cancer (26). Multidetector CT Technique We performed multidetector CT with a quad-channel scanner (MX 8000 Quad, Philips Medical Systems, Cleveland, Ohio) by using 0.5-second gantry rotation time and acquisition of 4 sections per rotation. All patients drank 500 mL of tap water as nonopaque oral intraluminal contrast media. A total of 150 mL (300 mg of iodine/mL) of low-osmolar contrast media (Isovue-300, Bracco Diagnostics, Princeton, New Jersey) was injected with a power injector (CT Envision Injector, Medrad, Pittsburgh, Pennsylvania) at a rate of 4.0 mL/s into an antecubital vein by using either an 18- or 20-gauge cannula. Examination was performed in a dual-phase mode. Image acquisition was first done during the pancreatic phase (35 seconds after the start of contrast infusion) from the top to the bottom of the pancreas with 4.0-mm beam collimation (nominal section thickness, 1.0 mm; effective section thickness, 1.3 mm), 0.5-mm reconstruction interval, 120 kVp, 205 mAs, and a pitch of 1.0 during a single breath-hold of 15 to 20 seconds. The second phase was performed during the portal venous phase (65 seconds after the start of contrast infusion) from the top of the liver to the iliac crests with 10-mm beam collimation (nominal section thickness, 2.5 mm; effective section thickness, 3.2 mm), 1.3-mm reconstruction interval, 120 kVp, 250 mAs, and a pitch of 0.875 during a single breath-hold of 15 seconds. Multiplanar (2-dimensional) reformatting was not routinely performed; however, when it was used, the entire data set was transferred to a workstation (MX View, Philips Medical Systems) for evaluation. No 3-dimensional (volume rendering) postprocessing was used in this study. One of 3 experienced gastrointestinal radiologists who were blinded to the results of the previous endoscopic ultrasonography examination interpreted all scans. Patient information provided to the interpreting radiologist included presenting symptoms; the size, location, and vascular involvement (if known) of any visualized pancreatic mass from previous CT; and the results of any previous endoscopic retrograde cholangiopancreatography (for example, presence or absence of ductal strictures) or pathology (for example, endoscopic brush cytology). Locoregional and distant adenopathy were considered malignant if they were greater than 10 mm in

Intraductal papillary mucinous neoplasms: Predictors of malignant and invasive pathology

Objective:Determine whether size and other preoperative parameters predict malignant or invasive intraductal papillary mucinous neoplasia (IPMN). Summary Background Data:From 1991 to 2006, 150 patients underwent 156 operations for IPMN. Methods:Prospectively collected, retrospective review of a single academic institutions experience. All preoperative parameters including a detailed radiologic-based classification of IPMN type, location, distribution, size, number, cytology, and mural nodularity were correlated with IPMN pathology. Results:Malignant IPMN was present in 32% of cases, whereas 19% of cases were invasive. IPMN type and main pancreatic duct diameter were significant predictors of malignant IPMN (P < 0.001). Side-branch lesion number was negatively associated with invasive IPMN (P = 0.03). Side-branch size, location, and distribution did not predict IPMN pathology. The presence of mural nodules was associated with malignant and invasive IPMN (P < 0.001; P < 0.02). Atypical cytopathology was significantly associated with malignant and invasive IPMN (P < 0.001; P < 0.001). Multivariate analysis demonstrated mural nodularity and atypical cytopathology were predictive of malignancy and/or invasion in branch-type IPMN. Conclusions:To lower the rate of invasive pathology, surgery should be recommended for fit patients with main-duct IPMN and for branch-duct IPMN with mural nodularity or positive cytology irrespective of location, distribution, or size.

EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study

BACKGROUND Surgery for pancreatic cysts is associated with significant morbidity. A pilot study previously demonstrated the safety of EUS-guided ethanol lavage of pancreatic cysts. OBJECTIVE To determine whether EUS-guided ethanol lavage would decrease pancreatic cyst size more than saline solution lavage. DESIGN Prospective, multicenter, randomized trial. SETTING Two tertiary referral hospitals in the United States. PATIENTS Patients referred for EUS with a 1- to 5-cm unilocular pancreatic cyst were randomized to blinded ethanol or saline solution lavage. Three months later, the cyst diameter was remeasured by EUS, and a second unblinded ethanol lavage was performed. INTERVENTIONS EUS-guided pancreatic cyst lavage. MAIN OUTCOME MEASUREMENTS Cyst ablation based on size changes from follow-up EUS, CT, and histology of resected specimens. RESULTS Of 58 patients randomized, 16 were excluded and 42 underwent initial ethanol (n = 25) or saline solution (n = 17) lavage. Ethanol lavage resulted in a greater mean percentage of decrease in cyst surface area (-42.9; 95% CI, -58.4 to -27.4) compared with saline solution alone (-11.4; 95% CI, -25.0 to 2.2; P = .009). Nineteen (76.0%) of 25 and 14 (82.3%) of 17 patients randomized to ethanol and saline solution, respectively, underwent a second ethanol lavage. A follow-up CT scan demonstrated resolution in 12 (33.3%) of 36 cysts. Histology of 4 resected cysts demonstrated epithelial ablation ranging from 0% (saline solution alone) to 50% to 100% (1 or 2 ethanol lavages). Complication rates were similar in all groups. LIMITATION Short-term follow-up. CONCLUSIONS EUS-guided ethanol lavage results in a greater decrease in pancreatic cyst size compared with saline solution lavage with a similar safety profile. Overall CT-defined complete pancreatic cyst ablation was 33.3%.

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability. Further controlled clinical studies may be needed to clarify aspects of these statements, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. ESGE guidelines are intended to be an educational device to provide information that may assist endoscopists in providing care to patients. They are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. METHODS A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. RESULTS Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. CONCLUSIONS EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

EUS-guided FNA of pancreatic metastases: a multicenter experience

BACKGROUND Metastatic lesions of the pancreas are a rare but important cause of focal pancreatic lesions. The purpose of this study is to describe the EUS features, cytologic diagnoses, and clinical impact of a cohort of patients with pancreatic metastases diagnosed by EUS-guided FNA (EUS-FNA). METHODS Over a 6-year period, in a retrospective, multicenter study, patients had the diagnosis of pancreatic metastases confirmed with EUS-FNA. All examinations were performed by one of 5 experienced endosonographers. The EUS and the clinical findings of pancreatic metastases were compared with those of a cohort with primary pancreatic malignancy. RESULTS Thirty-seven patients with possible metastases were identified, and 13 were excluded because of diagnostic uncertainty. The remaining 24 underwent EUS-FNA (mean passes 4.1) of a pancreatic mass without complications. Diagnoses included metastases from primary kidney (10), skin (6), lung (4), colon (2), liver (1), and stomach (1) cancer. In 4 (17%), 16 (67%), and 24 (100%) patients, EUS-FNA provided the initial diagnosis of malignancy, tumor recurrence, and pancreatic metastases, respectively. Four (17%) metastases initially were discovered by EUS after negative (n = 3) or inconclusive (n = 1) CT scans. Compared with primary cancer, pancreatic metastases were more likely to have well-defined margins (46% vs. 4%) compared with irregular (94% vs. 54%; p < 0.0001) margins. No statistically significant difference between the two populations was noted for tumor size, echogenicity, consistency, location, lesion number, or number of FNA passes performed. CONCLUSIONS Pancreatic metastases are an important cause of focal pancreatic lesions and may occasionally be discovered during EUS examination after previously negative or inconclusive CT. Use of immunocytochemistry, when available, may help to confirm a suspected diagnosis. These lesions are more likely to have well-defined EUS margins compared with primary pancreatic cancer.

The management of antithrombotic agents for patients undergoing GI endoscopy.

Ruben D. Acosta, MD, Neena S. Abraham, MD, MSCE, FASGE (invited content expert, ad-hoc member), Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, Dayna S. Early, MD, FASGE, Mohamad A. Eloubeidi, MD, MHS, FASGE, John A. Evans, MD, Ashley L. Faulx, MD, FASGE, Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE, Mouen A. Khashab, MD, Jenifer R. Lightdale, MD, MPH, FASGE, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, John R. Saltzman, MD, FASGE, Aasma Shaukat, MD, MPH, FASGE, Amandeep K. Shergill, MD, Amy Wang, MD, Brooks D. Cash, MD, FASGE, previous Committee Chair, John M. DeWitt, MD, FASGE, Chair

Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience.

BACKGROUND Accurate preoperative diagnosis and staging of cholangiocarcinoma (CCA) remain difficult. OBJECTIVE To evaluate the utility of EUS in the diagnosis and preoperative evaluation of CCA. DESIGN Observational study of prospectively collected data. SETTING Single tertiary referral hospital in Indianapolis, Indiana. PATIENTS Consecutive patients with CCA from January 2003 through October 2009. INTERVENTIONS EUS and EUS-guided FNA (EUS-FNA). MAIN OUTCOME MEASUREMENTS Sensitivity of EUS for the detection of a tumor and prediction of unresectability compared with CT and magnetic resonance imaging (MRI); sensitivity of EUS-FNA to provide tissue diagnosis, by using surgical pathology as a reference standard. RESULTS A total of 228 patients with biliary strictures undergoing EUS were identified. Of these, 81 (mean age 70 years, 45 men) had CCA. Fifty-one patients (63%) had distal and 30 (37%) had proximal CCA. For those with available imaging, tumor detection was superior with EUS compared with triphasic CT (76 of 81 [94%] vs 23 of 75 [30%], respectively; P < .001). MRI identified the tumor in 11 of 26 patients (42%; P = .07 vs EUS). EUS identified CCA in all 51 (100%) distal and 25 (83%) of 30 proximal tumors (P < .01). EUS-FNA (median, 5 passes; range, 1-12 passes) was performed in 74 patients (91%). The overall sensitivity of EUS-FNA for the diagnosis of CCA was 73% (95% confidence interval, 62%-82%) and was significantly higher in distal compared with proximal CCA (81% vs 59%, respectively; P = .04). Fifteen tumors were definitely unresectable. EUS correctly identified unresectability in 8 of 15 and correctly identified the 38 of 39 patients with resectable tumors (53% sensitivity and 97% specificity for unresectability). CT and/or MRI failed to detect unresectability in 6 of these 8 patients. LIMITATION Single-center study. CONCLUSION EUS and EUS-FNA are sensitive for the diagnosis of CCA and very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal than in proximal CCA.

Endoscopic ultrasound–guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

OBJECTIVES:The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound–guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.METHODS:A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.RESULTS:EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512–1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.CONCLUSION:EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.