Pancreatic cystic lesions (PCLs) are frequent incidental findings. As most PCLs require costly diagnostic evaluation and active surveillance, it is important to clarify their prevalence in ...asymptomatic individuals. We therefore aimed at performing a systematic review and meta-analysis to determine it.
Methods: a systematic search was conducted and studies meeting inclusion criteria were included. The prevalence of PCLs was pooled across studies. A random effect model was used with assessment of heterogeneity.
17 studies, with 48,860 patients, were included. Only 3 were prospective; 5 studies were conducted in the US, 7 in Europe, 4 in Asia and 1 in Brazil. The pooled prevalence of PCLs was 8% (95% CI 4–14) with considerable heterogeneity (I2 = 99.5%). This prevalence was higher in studies of higher quality, examining older subjects, smaller cohorts, and employing MRCP (24.8% vs 2.7% with CT-scan). The pooled rate of PCLs was four times higher in studies conducted in the US than in Asia (12.6% vs 3.1%). 7 studies reported the prevalence of mucinous lesions, with a pooled rate of 4.3% (95% CI 2–10; I2 = 99.2%), but of 0.7% only for worrisome features or high risk stigmata.
The rate of incidentally detected PCLs is of 8%. Mucinous lesions are the most common incidentally detected PCLs, although they rarely present with potential indication for surgery. The observed different rates in the US and other geographic Areas suggest that different protocols might be necessary to help balancing costs and effectiveness of follow-up investigations in asymptomatic subjects.
Previous studies investigating the association between statin use and pancreatic cancer (PDAC) risk for a possible chemopreventive effect gathered heterogeneous results.
To conduct a systematic ...review and meta-analysis to clarify this association.
Comprehensive literature search of articles published up to February 2018, including case-control (CC),cohort studies (C), randomized controlled trials (RCTs) assessing association between statin use and PDAC risk. Studies had to report odds ratio (OR)/relative risk (RR), estimates with 95% confidence interval (CI), or provide data for their calculation. Pooled ORs with 95%CIs were calculated using random effects model, publication bias through Begg and Mazumdar test and heterogeneity by I2 value.
27 studies(13 CC, 9C, 5 RCTs) for a total population of 11,975 PDAC/3,433,175 controls contributed to the analysis. The overall pooled result demonstrated a reduced PDAC risk among statin users (OR 0.70; 95% CI 0.60–0.82; p < 0.0001), compared to non-users. Sensitivity analyses suggested the risk reduction to be more important in CC studies, studies conducted in Asia and Europe, in males and atorvastatin users. No publication bias found.
The present meta-analysis suggests that statin use is associated with an overall PDAC risk reduction of 30%. Further studies are needed to clarify the association.
In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic ...GE (L-GE) are scarce. Our aim was to perform a propensity score–matched comparison between EUS-GE and L-GE.
An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging.
Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE–treated patients (94.6%) versus 100% in the L-GE group (P = .493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P = .358). Median time to oral intake (1 interquartile range {IQR}, .3-1.0 vs 3 IQR, 1.0-5.0 days, P < .001) and median hospital stay (4 IQR, 2-8 vs 8 IQR, 5.5-20 days, P < .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P = .007) and severe (.0% vs 16.2%, P = .025) adverse events were identified more frequently in the L-GE group.
For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable.
The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades.
An extensive bibliographical search was performed in PubMed to identify guidelines and primary ...literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms.
Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities.
Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.
Immunoglobulin G4-related disease (IgG4-RD) promptly responds to glucocorticoids but relapses in a considerable fraction of patients. Reliable biomarkers of flare are currently lacking because the ...pathophysiology of IgG4-RD remains largely elusive. In the present work, we aimed to identify perturbations of B-cell subpopulations that might predict IgG4-RD relapse.
Thirty patients were treated with glucocorticoids according to international guidelines. Circulating CD19
and CD20
cells, naive B cells, memory B cells, plasmablasts, and plasma cells were measured by flow cytometry at baseline and every 6 months for 2 years after the initiation of corticosteroid therapy.
Patients with active untreated IgG4-RD showed significantly reduced CD19
B cells, CD20
B cells, and naive B cells compared with healthy subjects (p < 0.05), but significantly expanded plasmablasts and plasma cells (p < 0.01). After 6 months of corticosteroid treatment, all patients achieved clinical improvement. Naive B cells, plasmablasts, and plasma cells significantly decreased compared with disease onset, whereas memory B cells significantly increased compared with baseline (p < 0.01). Increase of memory B cells was observed only in patients who relapsed within 2 years of follow-up, however (HR, 12.24; 2.99 to 50.2; p = 0.0005). In these patients, the relapse rates at 12 and 24 months were 30% and 100%, respectively. No abnormalities of other B-cell subpopulations at disease onset or after 6 months of glucocorticoid treatment were found to predict IgG4-RD relapse at 2 years.
Increase of circulating memory B cells after 6 months of glucocorticoid treatment might predict IgG4-RD relapse.
Objectives
Endoscopic ultrasound through‐the‐needle biopsy (EUS‐TTNB) is a useful tool for differential diagnosis among pancreatic cystic lesions (PCLs). Cystic fluid cytology (CFC) is recommended by ...guidelines, but its diagnostic accuracy is about 50%. The aim of this meta‐analysis is to assess the clinical impact of EUS‐TTNB in terms of technical success (TS), histological accuracy (HA) and diagnostic yield (DY).
Methods
Original studies in English language on EUS‐TTNB were searched in MEDLINE and EMBASE until October 2019. Diagnostic accuracy of EUS‐TTNB for identification of mucinous PCLs was calculated using individual diagnostic data of patients who underwent CFC and surgery.
Results
Nine studies, including 454 patients who underwent EUS‐TTNB, met the inclusion criteria for the meta‐analysis. TS and HA of EUS‐TTNB were, respectively, 98.5% (95% Confidence Interval CI 97.3%–99.6%) and 86.7% (95%CI 80.1–93.4). DY was 69.5% (95%CI 59.2–79.7) for EUS‐TTNB and 28.7% (95%CI 15.7–41.6) for CFC. Heterogeneity persisted significantly high in most of subgroup analyses. In the multivariate meta‐regression, cyst size was independently associated with higher DY. Sensitivity and specificity for mucinous PCLs were 88.6 and 94.7% for EUS‐TTNB, and 40 and 100% for CFC. Adverse events rate was 8.6% (95%CI 4.0–13.1).
Conclusions
This meta‐analysis shows that EUS‐TTNB is a feasible technique that allows a high rate of adequate specimens to be obtained for histology; in about two‐thirds of patients a specific histotype diagnosis could be assessed. The number of adverse events is slightly higher respect to standard EUS‐FNA, but complications are very rarely severe.
Objectives
Combined biliary obstruction and gastric outlet obstruction (GOO) represent a challenging clinical scenario despite developments in therapeutic endoscopic ultrasonography (EUS) as GOO ...might impair EUS‐guided biliary drainage. Little is known about the effectiveness of different therapeutic combinations used to treat double obstruction, especially regarding stent patency.
Methods
All consecutive patients with double obstruction treated between 2016 and 2021 in three tertiary academic centres were eligible for inclusion. Five combinations involving enteral stenting (ES), EUS‐guided gastroenterostomy (EUS‐GE), hepaticogastrostomy (EUS‐HGS), choledochoduodenostomy (EUS‐CDS), and transpapillary biliary stenting (TPS) were evaluated for dysfunction during follow‐up, either as proportions or dysfunction‐free survival (DFS) using Kaplan–Meier estimates.
Results
Ninety‐three patients were included (male 46%; age 67 interquartile range 60–76 years; pancreatic cancer 73%, metastatic 57%), resulting in 103 procedure combinations. Different combinations showed significantly different overall dysfunction rates (p = 0.009), ranging from the null rate of EUS‐GE+HG to the 18% rate of EUS‐GE+TPS, 31% of EUS‐GE+EUS‐CD, 53% of ES+TPS and 83% of ES+EUS‐CDS. Sub‐analyses restricted to biliary dysfunction confirmed these trends. A multivariate Cox proportional‐hazards regression of DFS, a stenosis distal to the papilla (HR 3.2 1.5–6.9) and ES+EUS‐CDS (HR 5.6 2–15.7) independently predicted dysfunction.
Conclusions
Despite a lack of statistical power per combination, this study introduces new associations beyond the increased risk of GOO recurrence with ES versus EUS‐GE. EUS‐CDS showed reduced effectiveness and frequent dysfunction in the context of GOO, especially when combined with ES. EUS‐GE+HGS or EUS‐GE+TPS in this setting might result in superior patency. These results suggest that a prospective evaluation of the optimal endoscopic approach to malignant double obstruction is needed.
Objectives
Long‐term outcomes of endoscopic ultrasound‐guided choledochoduodenostomy (EUS‐CDS) performed with lumen apposing metal stents (LAMS) have been poorly evaluated in small or retrospective ...series, leading to an underestimation of LAMS dysfunction.
Methods
All consecutive EUS‐CDS performed in three academic referral centers were included in prospectively maintained databases. Technical/clinical success, adverse events (AEs), and dysfunction during follow‐up were retrospectively analyzed. Kaplan–Meier analysis was used to estimate dysfunction‐free survival (DFS), with Cox proportional hazard regression to evaluate independent predictors of dysfunction.
Results
Ninety‐three patients were included (male 56%; mean age, 70 years 95% confidence interval (CI) 68–72; pancreatic cancer 81%, metastatic disease 47%). In 67% of procedures, 6 mm LAMS were used. Technical and clinical success were achieved in 97.8% and 93.4% of patients, respectively, with AEs occurring in 9.7% (78% mild/moderate). Dysfunction occurred in 31.8% of patients after a mean of 166 days (95% CI 91–241), with an estimated 6 month and 12 month DFS of 75% and 52%, respectively; mean DFS of 394 (95% CI 307–482) days. Almost all dysfunctions (96%) were successfully managed by endoscopic reintervention. Duodenal invasion (hazard ratio 2.7 95% CI 1.1–6.8) was the only independent predictor of dysfunction.
Conclusions
Endoscopic ultrasound‐guided choledochoduodenostomy shows excellent initial efficacy and safety, although stent dysfunctions occurs frequently during long‐term follow‐up. Almost all stent dysfunctions can be managed successfully by endoscopic reinterventions. We propose a comprehensive classification of the different types of dysfunction that may be encountered and rescue procedures that may be employed under these circumstances. Duodenal invasion seems to increase the risk of developing EUS‐CDS dysfunction, potentially representing a relative contraindication for this technique.
PDF
