Jose Lariño-Noia

Influence of On-Site Cytopathology Evaluation on the Diagnostic Accuracy of Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) of Solid Pancreatic Masses

OBJECTIVES:The aim of this study was to evaluate the influence of on-site cytopathological evaluation on the diagnostic yield of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for the differential diagnosis of solid pancreatic masses in an unselected series of consecutive patients.METHODS:Patients undergoing EUS-guided FNA of solid pancreatic lesions over a 2-year study period were included. Samples were either evaluated on site by a cytopathologist or processed by the endoscopist and sent to the pathology department for evaluation. Diagnostic accuracy for malignancy, number of needle passes, adequate-specimen collection rate, cytological diagnosis, and final diagnosis, and complication rate according to the presence or absence of on-site cytopathologist were evaluated.RESULTS:A total of 182 patients were included. An on-site cytopathologist was available in 95 cases (52.2%). There was no difference between groups in terms of age, sex, location, and size of the lesions. A significantly higher number of needle passes was performed when an on-site cytopathologist was not available (3.5±1.0 vs. 2.0±0.7; P<0.001). The presence of an on-site cytopathologist was associated with a significantly lower number of inadequate samples (1.0 vs. 12.6%, P=0.002), and a significantly higher diagnostic sensitivity (96.2 vs. 78.2%; P=0.002) and overall accuracy (96.8 vs. 86.2%; P=0.013) for malignancy. Three patients developed complications (two acute pancreatitis, one local bleeding), all of them belonging to the group without on-site cytopathology.CONCLUSIONS:On-site cytopathological evaluation improves the diagnostic yield of EUS-guided FNA for the cytological diagnosis of solid pancreatic masses. This is associated with a significantly lower number of inadequate samples and a lower number of needle passes.

EUS elastography for the characterization of solid pancreatic masses

BACKGROUND Differential diagnosis of solid pancreatic masses remains a challenge. EUS elastography, by analyzing tissue stiffness of the mass, may be of help in this setting. OBJECTIVE To evaluate the different elastographic patterns of solid pancreatic masses and the diagnostic accuracy of EUS elastography for malignancy. DESIGN Prospective, consecutive, descriptive study with a second blind evaluation of elastographic patterns for concordance analysis and use of a well-defined reference method for calculation of diagnostic accuracy. PATIENTS This study involved 130 consecutive patients with solid pancreatic masses and 20 controls with normal pancreases. INTERVENTION EUS elastography was performed by using a linear Pentax echoendoscope and Hitachi EUB-8500 US. MAIN OUTCOME MEASUREMENTS Elastographic patterns of solid pancreatic masses and accuracy of the technique for malignancy. RESULTS Mean (SD) size of the masses was 30.9 (12.5) mm. The final diagnosis was malignant tumor in 78 patients, inflammatory mass in 42 patients, and neuroendocrine tumor in 10 patients. Four elastographic patterns were described, with a high concordance among 2 blinded investigators. A green-predominant pattern, either homogeneous or heterogeneous, excluded malignancy with a high accuracy. On the contrary, a blue-predominant pattern, either homogeneous or heterogeneous, supported the diagnosis of malignant tumor. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of EUS elastography for diagnosis of malignancy were 100%, 85.5%, 90.7%, 100%, and 94.0%, respectively. LIMITATION Single-center study. CONCLUSION EUS elastography is a useful tool for differential diagnosis of solid pancreatic masses. It provides specific patterns supporting the benign or malignant nature of the disease.

Quantitative elastography associated with endoscopic ultrasound for the diagnosis of chronic pancreatitis.

BACKGROUND AND STUDY AIMS Endoscopic ultrasonography (EUS) has become the method of choice for the diagnosis of chronic pancreatitis in clinical practice. However, the criteria allowing the specific diagnosis of the disease, mainly at non-advanced stages, are still under debate. Analysis of tissue stiffness by quantitative EUS-elastography may provide additional relevant information in this setting. The aim of this study was to evaluate the information provided by quantitative EUS-elastography for the diagnosis of chronic pancreatitis. PATIENTS AND METHODS A prospective, consecutive, 1-year study was designed, and included patients who underwent EUS for epigastric pain syndrome or known chronic pancreatitis. EUS-elastography was performed using radial Pentax EUS and Hitachi EUB900. The strain ratio was measured in the head, body, and tail of the pancreas, and the elastographic result was the mean of these three values. EUS criteria of chronic pancreatitis and the Rosemont classification were also evaluated. Data were analyzed by analysis of variance and linear regression; diagnostic accuracy was based on the receiver operating characteristic (ROC) curve analysis. RESULTS A total of 191 patients (mean age 52 years, range 21 - 85; 103 male) were included; 92 (48.2 %) of them were finally diagnosed with chronic pancreatitis. A highly significant direct linear correlation was found between the number of EUS criteria of chronic pancreatitis and the strain ratio (r = 0.813; P < 0.0001). The area under the ROC curve was 0.949 (95 % confidence interval 0.916 - 0.982) and the accuracy of EUS-elastography for diagnosing chronic pancreatitis was 91.1 % (cut-off strain ratio of 2.25). The strain ratio varied significantly in different Rosemont classification groups (P < 0.001). CONCLUSIONS EUS-elastography was an accurate tool for the diagnosis of chronic pancreatitis and provided relevant and objective information to support EUS findings.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Smoking as a risk factor for complications in chronic pancreatitis.

Objectives Several recent studies have demonstrated the association between smoking and chronic pancreatitis (CP). However, less is known about the role of smoking in the development of CP-related complications. Our aim was to investigate the impact of smoking and alcohol consumption on age of onset and complications at CP diagnosis. Methods A cross-sectional case-case study was performed within a prospectively collected cohort of patients with CP. Alcohol consumption and smoking habits were assessed using a standardized questionnaire. Morphologic severity was defined based on endoscopic ultrasound criteria for CP and classified as mild (3–4 criteria), moderate (5–6 criteria), and severe (≥7 criteria or calcifications). Pancreatic exocrine insufficiency (PEI) was diagnosed using the 13C-mixed triglyceride breath test. Odds ratios (OR) with 95% confidence intervals (CI) for CP-related complications were calculated using a case-case design. Results A total of 241 patients were included. Smoking was associated with PEI (OR [95% CI], 2.4 [1.17–5.16]), calcifications (OR [95% CI], 2.33 [1.10–4.95]), and severe morphologic changes (OR [95% CI], 3.41 [1.31–8.85]) but not with pseudocysts or diabetes. Neither smoking nor alcohol consumption was associated with age of onset. Conclusions Tobacco, but not alcohol, is associated with PEI, calcifications, and severe morphologic (≥7 criteria or calcifications) CP at diagnosis. Smoking cessation should be encouraged in patients with CP.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: Part 1 (diagnosis)

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

EUS elastography to predict pancreatic exocrine insufficiency in patients with chronic pancreatitis

BACKGROUND Diagnosis of pancreatic exocrine insufficiency (PEI) is hindered by methodological difficulties of pancreatic function tests. The probability of PEI in chronic pancreatitis (CP) increases as pancreatic fibrosis develops. Pancreatic fibrosis in CP may be quantified by EUS elastography. OBJECTIVE To evaluate whether EUS-elastography can predict PEI in patients with CP. DESIGN Prospective, observational study. SETTING Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain. PATIENTS Patients diagnosed with CP based on EUS and magnetic resonance imaging and MRCP findings. INTERVENTIONS Diagnosis of PEI was based on the (13)C-mixed triglyceride breath test. EUS-elastography was performed with PENTAX echoendoscopes and Hitachi-Preirus US platform. Two areas were selected for elastographic evaluation: area A corresponds to the pancreatic parenchyma and area B to a soft peripancreatic reference area. The quotient B/A (strain ratio [SR]) was considered the elastographic result. MAIN OUTCOME MEASUREMENTS Pancreatic SR in CP patients with and without PEI. RESULTS A total of 115 patients with CP (mean age, 50.2 years, range, 21-81; 92 male) of different etiologies were included; 35 patients (30.4%) had PEI. Pancreatic SR was higher in patients with PEI (4.89; 95% confidence interval, 4.36-5.41) than in those with a normal breath test result (2.99; 95% confidence interval, 2.82-3.16) (P < .001). A direct relationship was found between the SR and the probability of PEI, which increases from 4.2% in patients with an SR less than 2.5 to 92.8% in those with an SR greater than >5.5. LIMITATIONS Single-center study. CONCLUSIONS The degree of pancreatic fibrosis as measured by EUS-guided elastography allows quantification of the probability of PEI in patients with CP.

The role of endoscopic ultrasound (EUS) in relation to other imaging modalities in the differential diagnosis between mass forming chronic pancreatitis, autoimmune pancreatitis and ductal pancreatic adenocarcinoma

Differential diagnosis of solid pancreatic lesions remains as an important clinical challenge, mainly for the differentiation between mass forming chronic pancreatitis, autoimmune pancreatitis and pancreatic adenocarcinoma. Endoscopic ultrasound (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) can all provide valuable and complementary information in this setting. Among them, EUS has the unique ability to obtain specimens for histopathological diagnosis and can therefore play a crucial role in the evaluation patients with inconclusive findings on initial exami nations. Nowadays, new developed techniques associated to EUS, like elastography and contrast enhancement, have shown promising results for the differential diagnosis of these pancreatic lesions.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

Objective: To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. Background: EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. Methods: Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. Results: These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. Conclusions: EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Endoscopic ultrasonography of the pancreas as an indirect method to predict pancreatic exocrine insufficiency in patients with chronic pancreatitis.

Objectives Functional evaluation of the pancreas is hindered by invasiveness and/or methodological difficulties. Endoscopic ultrasonography (EUS) provides with highly accurate images of pancreatic ducts and parenchyma. The aim of the study was to analyze the probability of pancreatic exocrine insufficiency (PEI) according to EUS criteria in patients with a diagnosis of chronic pancreatitis. Methods A total of 128 consecutive patients (mean age, 52 years; 104 men) with chronic pancreatitis were prospectively included. Pancreatic exocrine insufficiency was diagnosed by the carbon 13–mixed triglyceride breath test. Endoscopic ultrasonography was performed and EUS criteria of chronic pancreatitis evaluated by 2 different experienced endosonographers who were blinded to the results of the pancreatic function test. Results Forty-eight patients (37.5%) had PEI. The percentage of patients with PEI increased linearly with the number of EUS criteria. The presence of intraductal calcifications, hyperechogenic foci with shadowing, and dilation of the main pancreatic duct were significantly and independently associated to PEI. The probability of PEI in the presence of calculi in the main pancreatic duct is 80% and increases to 82.8% if, in addition, the main duct is dilated. Conclusions Endoscopic ultrasonography findings allow predicting the probability of PEI in patients with chronic pancreatitis and thus the need for pancreatic enzyme replacement therapy. Abbreviations CFA - coefficient of fat absorption EUS - endoscopic ultrasonography MTG - mixed triglyceride PEI - pancreatic exocrine insufficiency