M.C. Petrone

Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors.

BACKGROUNDnPreoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms.nnnMETHODSnWe conducted a bibliographic research using the National Library of Medicines PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests.nnnRESULTSnOne RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (pxa0<xa00.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, pxa0=xa00.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups.nnnCONCLUSIONSnAlthough the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device

BACKGROUND AND AIMSnSeveral studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle.nnnMETHODSnConsecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders.nnnRESULTSnA total of 608 patients were allocated to FNA (nxa0= 306) or FNB (nxa0= 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (Pxa0= .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, Pxa0< .001), accuracy for malignancy (87% vs 78%, Pxa0= .002) and Bethesda classification (82% vs 72%, Pxa0= .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; Pxa0= .004), and did not differ among centers (Pxa0= .836).nnnCONCLUSIONnThe 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, FNA pros

S71 Address for correspondence Dr. Maria Chiara Petrone, Pancreas Translational and Clinical Research Center, Pancreato-Biliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy. E-mail: petrone.mariachiara@hsr.it Received: 2017-07-12; Accepted: 2017-08-31 The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, FNA pros

OC.01.4 PREDICTIVE VALUE OF PRE-OPERATIVE STAGING AND GRADING IN PANCREATIC NEUROENDOCRINE NEOPLASMS

Background and aim: Pancreatic NeuroEndocrine Tumors (P-NETs) are a heterogeneous group of neoplasms with highly variable clinical behavior.In the attempt to assess a better prognostic description, the European Neuroendocrine Tumors Society (ENETS) proposed a new grading and TNM-based staging system. Aims of this study were to compare pre-operative and postoperative Staging and Grading in P-NETs and their prognostic significance; to determine if a new cut-off value of Ki-67 proliferative index for P-NETs Grading can improve the accuracy of prognostic stratification. Material and methods: Our retrospective study is composed of 285 patients with P-NETs observed at San Raffaele Scientific Institute from 1988 to 2012. Out of these, 90 and 42, respectively, were classified according to a new presurgical classification, composed of pre-operative Staging (CT, MRI, EUS) and Grading (EUS-guided FNA and cytological Ki-67 evaluation).Comparison between pre and post-operative models (Pre-Stage vs. Stage e Pre-Grade vs. Grade) was possible for 88 and 33 neoplasms, respectively. Ki-67 proliferative index was evaluated through immunocytochemical (Pre-Grade) and immunohistochemical (Grade) analyses. Agreement between pre-operative and post-operative models was performed through k-statistics (Cohen). A p-value <0.05 was considered significant. Results: Among all pre-operative and post-operative models, Pre-Grade shows the highest Harrell’s C (0.97), resulting the best tool for a proper prognostic stratification. When comparing pre-operative and post-operative models, percent agreement between Pre-Stage and Stage was good (83%, k=0.74), otherwise agreement between Pre-Grade and Grade was moderate (70%, k=0.42), when used a 2% cut-off for Grade 1 tumor definition; contrarily, when used a 5% cut-off, Pre-Grade and Grade showed a good agreement (88%, k=0.66). The definition of a new 5% cut-off for cytological and histological Ki-67 index improved the accuracy of patients’ prognostic stratification, being not significant the difference between patients’ 10-year survival for Ki-67 levels within 5% (93.75% vs. 90%). Conclusions: The new proposed pre-surgical classification, based on PreStage and Pre-Grade, is comparable to post-surgical models. This system shows a good agreement with post-surgical one, being efficient in pre-surgical disease’s biology evaluation.