Background This retrospective cohort study analyzes the potential risks associated with preoperative fine needle aspiration (FNA) biopsy guided by endoscopic ultrasonography (EUS) in patients ...undergoing distal pancreatectomy. Methods Excluding 204 patients with acute or chronic pancreatitis and those with previous pancreatic resections, 230 consecutive patients with primary pancreatic neoplasms underwent elective distal pancreatectomy between 2002 and 2009. The most common indications were adenocarcinoma (28%), intraductal papillary mucinous neoplasm (IPMN; 20%), and endocrine neoplasms (17%). Two-way statistical comparisons were performed between patients who did (EUS+ ) or did not (EUS− ) undergo preoperative EUS-FNA. Results Distal pancreatectomy was performed open in 118 patients (56%) and laparoscopically in 102 patients (44%). No differences were observed in age, sex, American Society of Anesthesiologists class, operative time, or blood loss between the EUS+ ( n = 179) and EUS− ( n = 51) groups. Splenectomy was performed in 162 patients (70%) and was more common in the EUS+ group. With the exception of adenocarcinoma ( n = 57 32% EUS+ vs n = 6 12% EUS− ; P < .01), the final pathologic diagnosis did not differ significantly between the EUS groups. Postoperative complications were more common in the EUS+ patients with cystic neoplasms (43% vs 16% EUS− ; P = .04). EUS-FNA caused pancreatitis in 2 patients preoperatively. No differences in overall or recurrence-free survival were noted between cancer patients in the EUS groups. Patterns of tumor recurrence were not associated with EUS-FNA. Conclusion Preoperative EUS-FNA is not associated with adverse perioperative or long-term outcomes in patients undergoing distal pancreatectomy for solid neoplasms of the pancreas. The potentially detrimental long-term impact of preoperative EUS-FNA in patients with resectable pancreatic adenocarcinoma was not observed, but will require additional study.
Background & Aims Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%–90% of patients, although percentages in the United States are unknown. We investigated the ...epidemiology of alcohol-related CP at tertiary US referral centers. Methods We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified). Results The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women ( P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP. Conclusions The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.
The Collaborative Alliance for Pancreatic Education and Research developed Pancreas Academy as a lecture-based conference with the goal of providing practical guidance in the diagnosis and management ...of pancreatic diseases for health care providers. Since its inception in 2017, attendance at Pancreas Academy has steadily grown every year, with trainees accounting for the largest proportion of attendees. The proportion of advanced practice providers and pediatric specialists attending the conference, although relatively low, has also risen each year. Despite the growth in the conference, this report highlights the need for continued outreach to primary care providers, nonphysicians, and nongastroenterologists to provide health care providers at all levels pragmatic and essential knowledge in caring for patients with pancreatic diseases.
Background Bariatric surgery remains the most effective treatment for the management of obesity. Endoluminal interventions offer the potential for an ambulatory weight loss procedure that may be ...safer and more cost-effective compared with current laparoscopic approaches. Objective We review the currently available endoluminal techniques for obesity that have been presented or discussed in public forums and meetings, focusing on those with published trials. Design Literature review. Results Human trials of endoluminal treatments of obesity are primarily limited to restrictive interventions, including intragastric balloons, transoral gastroplasty, and endoluminal vertical gastroplasty. Currently, the duodenojejunal bypass sleeve is the only endoluminal device that has been studied in humans that promotes weight loss through malabsorption. Early results of these technologies are promising, but long-term data are lacking. Conclusions Endoluminal treatments for obesity have promise, and recent technological advances have been astounding. However, these interventions will need to be held to the same standards of current operative techniques. Each device will need to be scrutinized within clinical trials to determine its safety, efficacy, and durability.
Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the ...Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology.
A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets.
Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary.
Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.
Background
Pain is the most debilitating symptom of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) and often requires chronic opioids or total pancreatectomy with islet ...autotransplantation to manage. Pain is a complex experience that can be exacerbated by depression and vice versa. Our aim was to test the hypothesis that depression-associated genes are associated with a constant-severe pain experience in RAP/CP patients.
Study
A retrospective study was done using North American Pancreatitis Study II (NAPS2) genotyped RAP and CP patients with completed case report forms (
n
= 1,357). Subjects were divided based on pattern of pain and pain severity as
constant-severe pain
(
n
= 787) versus
not constant-severe pain
(
n
= 570) to conduct a nested genome-wide association study. The association between reported antidepressant medication use and depression gene loci was tested.
Results
Constant-severe pain was reported in 58% (
n
= 787) of pancreatitis patients. No differences in sex or alcohol consumption were found based on pain severity. Antidepressant use was reported in 28% (
n
= 223), and they had lower SF-12 mental quality of life (MCS,
p
< 2.2 × 10
− 16
). Fifteen loci associated with constant-severe pain (
p
< 0.00001) were found to be in or near depression-associated genes including
ROBO2, CTNND2, SGCZ, CNTN5
and
BAIAP2
. Three of these genes respond to antidepressant use (
SGCZ, ROBO2,
and
CTNND2
).
Conclusion
Depression is a major co-factor in the pain experience. This genetic predisposition to depression may have utility in counseling patients and in instituting early antidepressant therapy for pain management of pancreatitis patients. Prospective randomized trials are warranted.
Clinical trials registration
Clinicaltriasl.gov.# NCT01545167
Background Successful cannulation of the common bile duct (CBD) remains the benchmark for ERCP. Use of a pancreatic duct (PD) stent to facilitate biliary cannulation has been described, although the ...majority of patients require precut sphincterotomy to achieve CBD cannulation. Objective To report the performance characteristics of using a PD stent in conjunction with physician-controlled wire-guided cannulation (WGC) to facilitate bile duct cannulation. Design Retrospective cohort. Setting Two tertiary care, academic medical centers. Patients All undergoing ERCP with native papillae. Intervention In cases of difficult biliary access in which the PD is cannulated, a pancreatic stent is placed. After this, physician-controlled WGC is attempted by using the PD stent to direct the sphincterotome into the biliary orifice. If cannulation is unsuccessful after several minutes, a precut sphincterotomy is performed over the PD stent or the procedure is terminated. Main Outcome Measurements Frequency of successful bile duct cannulation and precut sphincterotomy. Results A total of 2345 ERCPs were identified, 1544 with native papillae. Among these, CBD and PD cannulation failed in 16 (1.0%) patients, whereas 76 (4.9%) patients received a PD stent to facilitate biliary cannulation. Successful cannulation was achieved in 71 (93.4%) of 76 patients, 60 (78.9%) of whom did not require precut sphincterotomy. Complications included mild post-ERCP pancreatitis in 4 (5.3%) and aspiration in 1 (1.3%). Precut sphincterotomy was complicated by hemorrhage, controlled during the procedure in 2 (13.3%) of 15. Conclusions Physician-controlled WGC over a PD stent facilitates biliary cannulation while maintaining a low rate of precut sphincterotomy.
The concept that sphincter of Oddi dysfunction (SOD) can cause attacks of biliary-type pain in postcholecystectomy patients and those with unexplained recurrent acute pancreatitis, and that ...endoscopic sphincterotomy can ameliorate symptoms, remains unproven. The Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) study of patients without objective evidence for biliary obstruction showed no difference in outcomes between those who underwent sphincterotomy or sham treatment.
To date, there have been no studies examining the characteristics of patients who still are being offered endoscopic retrograde cholangiopancreatography (ERCP) for SOD since the EPISOD publication, although the absolute number appears to have declined.
.
Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in ...the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a “high-quality” nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs.
The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods.
Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures.
This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education’s Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency.
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