P.A. Testoni

Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology

BACKGROUND Magnetic resonance cholangio-pancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic cholangio-pancreatography (ERCP) are the most frequently employed second-step procedures to detect biliary and pancreatic abnormalities in patients with acute recurrent pancreatitis (ARP) of unknown aetiology. MRCP and EUS both give a better view of the bilio-pancreatic ductal system after secretin stimulation (MRCP-S, EUS-S). EUS also serves to identify changes in the pancreatic parenchyma consistent with chronic pancreatitis, at an early stage. However, no studies have compared MRCP-S, EUS-S, and ERCP in the diagnosis of recurrent pancreatitis. AIM To prospectively compare the diagnostic yield of MRCP-S, EUS-S, and ERCP in the evaluation of patients with acute recurrent pancreatitis with non-dilated ducts, of unknown aetiology. METHODS Forty-four consecutive patients with ARP were prospectively scheduled to undergo MRCP-S, EUS-S and ERCP, in accordance with a standard protocol approved by the institutional review board. Diagnoses such as biliary microlithiasis, congenital variants of the pancreatic ducts, chronic pancreatitis and sphincter of Oddi dysfunction were compared between the three procedures. The diagnosis of chronic pancreatitis was established according to ductal morphology by MRCP-S and ERCP, ductal and parenchymal morphology by EUS-S. RESULTS The three procedures combined achieved a diagnosis that could have explained the recurrence of pancreatitis in 28/44 patients (63.6%). EUS-S recognized ductal and/or parenchymal abnormalities with the highest frequency (35/44 patients, 79.5%). Both MRCP-S and EUS-S were superior to ERCP for detecting pancreatic ductal abnormalities. EUS-S showed up pancreatic parenchymal changes in more than half the cases. Both EUS and MRCP secretin kinetics were concordant in identifying two cases with sphincter of Oddi dysfunction. CONCLUSIONS The diagnostic yield of EUS-S in recurrent pancreatitis with non-dilated ducts and unknown aetiology was 13.6% and 16.7% higher than MRCP-S and ERCP respectively (although not significant), which both gave substantially similar diagnostic yields. In no case did ERCP alone find a diagnosis missed by the other two procedures. MRCP-S and EUS-S should both be used in the diagnostic work-up of idiopathic recurrent pancreatitis as complementary, first-line, techniques, instead of ERCP.

Longterm oral cisapride improves interdigestive antroduodenal motility in dyspeptic patients.

We have evaluated the effect of cisapride on interdigestive antroduodenal motility during a prolonged oral therapy in 20 consecutive dyspeptic subjects. Individuals with less than two migrating motor complexes (MMCs) starting from the antral region in 240 minutes and without evidence of upper gastrointestinal tract diseases were randomly treated with either cisapride (10 cases), or placebo (10 cases) for 15 days. Computerised manometry of antroduodenal region was performed for 240 minutes, in basal conditions and on the 15th day of therapy. Symptomatic evaluation of patients was also performed before and after treatment. After cisapride administration, a significant increase in the incidence of antral migrating motor complexes was noticed (p = 0.022); likewise, the motility index, calculated for phase-2 periods, appeared to be significantly higher both in the antrum and in the duodenum (p less than 0.001). Symptomatic improvement was observed in both groups, with a hardly significant (p = 0.049) reduction of dyspeptic symptoms severity only but not of frequency in cisapride treated patients v controls. We conclude that longterm oral therapy with cisapride improves interdigestive antroduodenal motor activity.

Are we meeting the standards set for ERCP

ERCP practice today: implications for training The study by Williams et al , 1 published in this issue of Gut (see page 796) , reports the findings of a UK National Confidential Enquiry into Patient Outcomes and Deaths relating to endoscopic retrograde cholangiopancreatography (ERCP). Approximately 48 000 ERCPs are performed annually in the UK. For this study, five metropolitan areas of England were surveyed. The authors estimate that about 20% of all the ERCP procedures performed in adults (>18 years of age) over a 6-month period were captured. The results offer a cornucopia of food for thought. In all, 94% (76/81) of endoscopy units polled responded. Personal questionnaires were returned by 89% of staff endoscopists and by 81% of their trainees. Aspects of ERCP that were examined ranged from the experience and success of the physicians performing the procedures, to indications, informed consent, adequacy of monitoring and resuscitation, and outcomes, including complications and mortality. More than a few of the findings are sobering, concerning and demand remedial action. But we acknowledge that it is easy to be an armchair critic of another country’s ERCP practice. An in-depth look at ERCP practice in the US and Italy, for example, would probably reveal some, if not many, of the same problems arising from marginal training, inexperience, inadequate volume of cases to maintain skills and so on. The current study looked at the success rates of trainees as a function of their experience. Those with experience of >200 ERCPs had an unsupervised cannulation rate (to enter the duct of choice) of 66%; this fell to 40% for those with experience of <200 ERCPs. The overall trainee cannulation success rate with procedures whose trainee involvement was not documented, was reportedly 54%. The American Society for Gastrointestinal Endoscopy (ASGE) considers a selective cannulation success …

Manometric evaluation of the interdigestive antroduodenal motility in subjects with fasting bile reflux, with and without antral gastritis.

The interdigestive antroduodenal motor activity was studied in 15 patients with bile reflux without gastritis (group A), 17 with bile reflux and chronic antral superficial gastritis (group B) and in nine healthy controls (group C), by manometric recording of phases of the interdigestive motility complex (IDMC) over 240 minutes, or until two consecutive migrating motor complexes (MMCs) had been recorded, whichever the shorter. In the patients with bile reflux the occurrence of MMCs was decreased and median duration of the IDMC was significantly prolonged (group A = 162.5 min; group B = 185.0 min), compared with controls (group C = 92.0 min; p less than 0.01 v groups A and B). There were no differences in motility pattern between patients with and without gastritis, suggesting that motor abnormalities are not caused by gastritis, but may precede its occurrence. Delayed occurrence of motor activity fronts increases duodenogastric reflux, but correlation with gastric mucosal lesions was not shown, suggesting that other mechanisms are involved.

Optical coherence tomography in the diagnosis of coeliac disease: a preliminary report

Coeliac disease (CD) is a common condition with many atypical manifestations and an estimated worldwide prevalence of 1 in 266.1 It often goes unrecognised because characteristic histopathological abnormalities must be found to confirm the diagnosis. Endoscopic signs of CD are described in the literature but cannot be relied upon for detection of the disease because their sensitivity and specificity are not high. To investigate CD in every patient undergoing oesophagogastroduodenoscopy (OGD) for dyspeptic symptoms is not realistic, especially if we consider the significant costs of histological handling. Therefore, a way of detecting CD is selection of patients in which biopsies of the duodenal mucosa must be performed. A useful new medical technique, optical coherence tomography (OCT), that combines the principles of ultrasound and infrared backscattering light, …

Investigation of Oddi sphincter structure by optical coherence tomography in patients with biliary-type 1 dysfunction: A pilot in vivo study

BACKGROUND Type 1 sphincter of Oddi dysfunction is a clinical entity characterised by biliary-type pain, elevated liver biochemical tests, and common bile duct dilation. Sphincter fibrosis is a common finding in this type of dysfunction and may require in some cases a differential diagnosis with a malignant intra-papillary disease. Optical coherence tomography permits high-resolution, real-time imaging of the sphincter of Oddi microstructure by a probe inserted into the common bile duct through an ERCP catheter. No data exist on the evaluation of sphincter of Oddi fibrosis by optical coherence tomography during ERCP in vivo. OBJECTIVE To assess the feasibility of optical coherence tomography investigation of the sphincter of Oddi structure and assess its potential for diagnosing type 1 sphincter of Oddi dysfunction. PATIENTS Ten consecutive patients, five with biliary-type 1 sphincter of Oddi dysfunction and five with pancreatic head/mid-body adenocarcinoma not involving the papillary region, who underwent both endoscopic ultrasound and therapeutic ERCP, were investigated by optical coherence tomography immediately before biliary sphincterotomy or stenting. RESULTS In all sphincter of Oddi dysfunction patients optical coherence tomography recognised a hyper-reflective intermediate, fibro-muscular layer, significantly thicker than in patients with non-pathological sphincter of Oddi (p<0.0001). CONCLUSIONS Optical coherence tomography imaging recognised an increased thickness and reflectance of the fibro-muscular layer of the sphincter of Oddi, very likely determined by fibrosis, and was not time-consuming; it can be safely used during ERCP to confirm the diagnosis in difficult cases. Its use in clinical practice has one important limitation since it requires magnification in the post-procedure computer analysis to obtain images useful for diagnosis.

Same-day laparoscopic cholecystectomy and ERCP for choledocholithiasis

Given that most of the stones found in this study were small, we were surprised by the frequent use of balloon dilation of the sphincterotomy and liberal placement of biliary stents to guarantee drainage. The introduction of laparoscopic cholecystectomy (LC) around 1990 changed the ERCP landscape almost instantly. Like the giant asteroid that doomed the dinosaurs 65.5 million years ago, the arrival of LC was an extinction level event for extracorporeal shock wave lithotripsy (ESWL), which had caught the public’s imagination as a way to avoid major abdominal surgery. With the widespread adoption of LC, ESWL for gallstones became obsolete almost overnight. Suddenly, the demand was for ERCP to look for and, if necessary, remove common bile duct stones (CBDS) before LC. Unfortunately, there was also a significant demand for endoscopic cholangiography to evaluate and treat biliary leaks and injuries. The price to be paid for the surgical learning curve in LC was a rash of bile duct injuries and transections that kept specialist biliary surgeons and malpractice lawyers busy for years. Over time, the technology and technique of LC matured to a point at which injuries and leaks became infrequent, so that the principal indication for ERCP became the hunt for CBDS. In the early days of LC, there was a determined effort to establish laparoscopic bile duct exploration (LBDE) as an alternative to ERCP. This was fueled in large part by the concern of surgeons that leaving CBDS for endoscopists to deal with was a gamble, because ERCP for stone removal might fail and require a second open surgical procedure. Worse still, the failed ERCP might be complicated by acute pancreatitis, bleeding, or perforation. Because many bile duct stones are small (5 mm or less) and occur in nondilated ducts, LBDE can be technically demanding and sometimes fails, although in experienced hands the results equal those of ERCP. Without doubt it adds time to the standard LC procedure. The majority of surgeons performing LC in the United States have not embraced LBDE and prefer to leave these cases to endoscopists, who are usually eager to perform ERCP. To address concerns about failed ERCPs, in nonurgent cases these procedures are often done days to weeks in advance of LC, so that a tertiary center ERCP referral can be made for another attempt if necessary. An ERCP endoscopist who can cannulate the bile duct 95% of the time or more, and complete stone removal with

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.

Alkaline reflux gastritis after partial gastrectomy: Evidence for a pathogenetic role of deoxycholic acid

30 subjects submitted to Billroth II resection for duodenal ulcer were divided in two groups: 15 patients with severe remnant gastritis at endoscopic examination confirmed by histology and 15 control