Outcomes of a 3-Year Prospective Surveillance in Individuals at High Risk of Pancreatic Cancer

INTRODUCTION

Pancreatic cancer (PC) surveillance of high-risk individuals (HRI) is becoming more common worldwide, aiming at anticipating PC diagnosis at a preclinical stage. In 2015, the Italian Registry of Families at Risk of Pancreatic Cancer was created. We aimed to assess the prevalence and incidence of pancreatic findings, oncological outcomes, and harms 7 years after the Italian Registry of Families at Risk of Pancreatic Cancer inception, focusing on individuals with at least a 3-year follow-up or developing events before.

METHODS

HRI (subjects with a family history or mutation carriers with/without a family history were enrolled in 18 centers). They underwent annual magnetic resonance with cholangiopancreatography or endoscopic ultrasound (NCT04095195).

RESULTS

During the study period (June 2015-September 2022), 679 individuals were enrolled. Of these, 524 (77.2%) underwent at least baseline imaging, and 156 (29.8%) with at least a 3-year follow-up or pancreatic malignancy/premalignancy-related events, and represented the study population. The median age was 51 (interquartile range 16) years. Familial PC cases accounted for 81.4% of HRI and individuals with pathogenic variant for 18.6%. Malignant (n = 8) and premalignant (1 PanIN3) lesions were found in 9 individuals. Five of these 8 cases occurred in pathogenic variant carriers, 4 in familial PC cases (2 tested negative at germline testing and 2 others were not tested). Three of the 8 PC were stage I. Five of the 8 PC were resectable, 3 Stage I, all advanced cases being prevalent. The 1-, 2-, and 3-year cumulative hazard of PC was 1.7%, 2.5%, and 3%, respectively. Median overall and disease-free survival of patients with resected PC were 18 and 12 months (95% CI not computable). Considering HRI who underwent baseline imaging, 6 pancreatic neuroendocrine neoplasms (1 resected) and 1 low-yield surgery (low-grade mixed-intraductal papillary mucinous neoplasm) were also reported.

DISCUSSION

PC surveillance in a fully public health care system is feasible and safe, and leads to early PC or premalignant lesions diagnoses, mostly at baseline but also over time.

SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Fusion radiology in interventional endoscopy (FRIend): a new approach for pancreatic fluid collections

Background and study aims  Fusion imaging consists of overlaying preoperative imaging over live fluoroscopy, providing an augmented live guidance. Since 2017, we have been using a new hybrid operating room (Discovery IGS 740 OR, GE Healthcare) for biliopancreatic endoscopy, combining fusion imaging with traditional endoscopic ultrasound (EUS). This study aimed to assess the advantages that fusion imaging could bring to EUS-guided drainage of post-pancreatitis fluid collections. Patients and methods  Thirty-five drainage procedures performed between 2012 and 2019 with traditional guidance and fusion imaging were retrospectively compared, assessing the overall treatment success rate - i. e. symptom improvement with complete PFC emptying - as a primary outcome. Secondary outcomes included technical success rate, time to resolution, hospital stay length, adverse events, recurrence rate, and procedure time. Results  Patients treated with standard EUS (n = 17) and with fusion imaging (n = 18) were homogeneous in age, gender, pancreatitis etiology, and indication for drainage; the second group had larger PFCs, more frequently walled-off necrosis than pseudocysts, and were treated more emergently, indicating higher case complexity in this group. During the period when fusion imaging was adopted, procedures had a higher overall treatment success rate than during the period when standard EUS was adopted (83.3 % vs. 52.9 %, P  = 0.075), and complete emptying was reached in less time (61.1 % vs. 23.6 % complete emptying within 90 days, P  = 0.154), differences compatible with random fluctuations. Conclusions  This study suggests that fusion imaging in combination with EUS might improve clinical and procedural outcomes of PFC drainage.

Successful Endovascular and Endoscopic Treatment of a Symptomatic Celiac Artery Aneurysm for Obstructive Jaundice: A Clinical Case Report

BACKGROUND

Celiac artery aneurysm (CAA) is an infrequent aneurysm of the celiac visceral branch and is potentially life-threatening, mainly due to the risk of rupture. CAA is often diagnosed following rupture and rarely diagnosed secondary to a primary manifestation; obstructive jaundice is extremely rare and poorly described. This clinical case report reports a combined endovascular and endoscopic noninvasive treatment.

METHODS

A 51-year old male was admitted to the emergency department at the Arcispedale Santa Maria Nuova in Reggio Emilia following several days of jaundice. The patient did not have any history of abdominal trauma, chronic pancreatitis, bile duct calculus or alcohol abuse. Cholestatic impairment was demonstrated by blood analyses and abdominal ultrasound revealed a large cephalo-pancreatic mass. Contrast-enhanced computed tomography (CT) showed a 40 mm CAA, causing a common bile duct (CBD) compression and dilatation of the hepatic bile ducts. After a multidisciplinary team consultation, a noninvasive, combined endovascular and endoscopic approach was programmed in a hybrid room.

RESULTS

Immediate results confirmed successful exclusion of the CAA, stent graft patency and the absence of endoleak with correct positioning of a plastic stent in the CBD. At 1 month, an abdominal CT-angiography (CTA) evidenced a type II endoleak, successfully treated with an endovascular secondary procedure and an asymptomatic, partial downward dislodgement of the plastic stent in the CBD was correct with the positioning of 2 plastic stents. At 3-months cholangiography showed no dilation of intraepatic biliary ducts.

CONCLUSIONS

Symptomatic CAA with common bile duct compression could be amenable to a combined endovascular and endoscopic noninvasive treatment.

Impact of multidisciplinary approach and radiologic review on surgical outcome and overall survival of patients with pancreatic cancer: a retrospective cohort study

AIM

To evaluate the impact of multidisciplinary team case discussion including computed tomography (CT) radiologic review on surgical outcome and overall survival (OS) of patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients with PDAC evaluated in 2008-2011 and 2013-2016 (before and after multidisciplinary team introduction), aged <85 years and staged I-III, were included. Surgical failures and 2-year OS were compared in these periods. Available CT scans of preintervention period (2008-2011) cases were reviewed by two radiologists in consensus, assigning a resectability judgment to evaluate in how many cases a different recommendation would be achieved.

RESULTS

A total of 316 patients (49.3% female, age 71±10 years) were included: 132 in 2008-2011 and 184 in 2013-2016. The proportion of patients who underwent upfront surgery was similar in the two periods (51% vs 47% in 2008-2011 vs 2013-2016). Neoadjuvant referral increased from 7% to 21% and surgical resection was excluded for 42% patients in 2008-2011 vs 33% in 2013-2016 (p = 0.002). Adjusting by age, sex, and stage, surgical failures slightly decreased in 2013-2016 (odds ratio 0.89, 95% confidence interval 0.53-1.51); the decrease was stronger when therapeutic choice complied with CT indications (odds ratio 0.76, 95% confidence interval 0.36-1.63); in both cases, the decrease could be due to chance. After correction for age, sex, and stage, the hazard ratio of 2013-2016 for OS was 0.83 (95% confidence interval 0.64-1.09). In 33/114 (29%) patients, CT retrospective review produced a change in resectability judgment.

CONCLUSION

Although differences could be due to chance or generic improvement, the consistency between process and outcome indicators suggests that multidisciplinary team approach with radiologic review may improve outcomes.

Endoscopic Papillectomy for Ampullary Adenomas: Different Outcomes in Sporadic Tumors and Those Associated with Familial Adenomatous Polyposis

BACKGROUND

Ampullary adenomas are rare and potentially malignant. Surgery was the standard treatment but endoscopic papillectomy (EP) is a possible alternative.

AIM

We retrospectively evaluated the principal clinical outcomes of EP in all patients referred to our unit also dividing sporadic ampullary adenoma (SAA) from familial adenomatous polyposis (FAP)-associated adenomas.

METHODS

All consecutive patients who underwent endoscopic papillectomy because of ampullary adenoma were considered. The primary outcome was the technical success of EP. Secondary outcomes included the number of procedures, the adverse event rate, the recurrence rate, the concordance of histology pre- and post-EP, and the evaluation of factors related to technical success.

RESULTS

Between January 2001 and December 2015, sixty-two patients were included (21 FAP and 41 SAA). Technical success was achieved in 75.8% and was different in the two groups (FAP 95.2%, SAA 65.8%, p 0.025). Intraductal invasion was negatively associated with technical success (41.7% vs. 84.0%; p 0.005). The intestinal subtype was predictive of success (79.7% vs. 0%; p 0.012) as well as en bloc resection (90.3% vs. 61.3%; p 0.016). Adverse events were reported in 14 patients (22.6%).

CONCLUSIONS

EP is an effective and safe procedure and is a viable alternative to surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03494543.

Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction after failed ERCP in low performance status patients

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) with the placement of a biliary stent is the treatment of choice for palliation of malignant obstructive jaundice. In 5-10% of cases ERCP fails. In these cases an effective alternative is endoscopic ultrasonography-guided biliary drainage (EUS-BD).

AIM

Evaluation of the principal clinical outcomes of direct transluminal EUS-BD.

PATIENTS AND METHODS

This study is a retrospective analysis. All consecutive patients with malignant obstructive jaundice, in whom ERCP had failed, were enrolled. The primary outcome was the technical success of EUS-BD defined as the correct placement of the metal or plastic stent across the stomach or duodenum to the biliary tree. The most important secondary outcomes were early and late clinical success, both linked to the decrease of bilirubin haematic level.

RESULTS

Between January 2011 and November 2017 thirty-six patients were included. Technical success was obtained in 91.6%. A clinical success, early or late was obtained in 75.8%. The ECOG performance status of less than 3 was correlated with clinical success. Adverse events occurred in 30.3% of patients.

CONCLUSIONS

EUS-BD is an effective and safe procedure.

Full-spectrum (FUSE) versus standard forward-viewing colonoscopy in an organised colorectal cancer screening programme

OBJECTIVE

Miss rate of polyps has been shown to be substantially lower with full-spectrum endoscopy (FUSE) compared with standard forward-viewing (SFV) colonoscopy in a tandem study at per polyp analysis. However, there is uncertainty on whether FUSE is also associated with a higher detection rate of colorectal neoplasia, especially advanced lesions, in per patient analysis.

METHODS

Consecutive subjects undergoing colonoscopy following a positive faecal immunochemical test (FIT) by experienced endoscopists and performed in the context of a regional colorectal cancer population-screening programme were randomised between colonoscopy with either FUSE or SFV colonoscopy in seven Italian centres. Randomisation was stratified by gender, age group and screening history. Primary outcomes included detection rates of advanced adenomas (A-ADR), adenomas (ADR) and sessile-serrated polyps (SSPDR).

RESULTS

Of 741 eligible subjects, 658 were randomised to either FUSE (n=328) or SFV (n=330) colonoscopy and included in the analysis. Overall, 293/658 and 143/658 subjects had at least one adenoma (ADR 44.5%) and advanced adenoma (A-ADR 21.7%), respectively, while SSP was the most advanced lesion in 18 cases (SSPDR 2.7%). ADR and A-ADR were 43.6% and 19.5% in the FUSE arm, and 45.5% and 23.9% in the SFV arm, with no difference for both ADR (OR for FUSE: 0.96, 95% CI 0.81 to 1.14) and A-ADR (OR for FUSE: 0.82, 95% CI 0.61 to 1.09). No difference in SSPDR or multiplicity was detected between the two arms. In the per polyp analysis, the mean number of adenomas and proximal adenomas per patient was 0.81±1.25 and 0.47±0.93 in the FUSE arm, and 0.85±1.33 and 0.48±0.96 in the SFV colonoscopy arm (p=NS for both comparisons).

CONCLUSIONS

No statistically significant difference in ADR and A-ADR between FUSE and SFV colonoscopy was detected in a per patient analysis in FIT-positive patients.

TRIAL REGISTRATION NUMBER

ISRCTN10357435.

Inflammatory bowel diseases and human reproduction: a comprehensive evidence-based review

To evaluate the effects of inflammatory bowel diseases (IBDs) on human reproduction, we reviewed the current literature using a systematic search for published studies (articles and/or abstracts) without limits for English language. We searched on Medline (through PubMed), the Institute for Scientific Information, the Web of Science and the websites for the registration of controlled trials (http://controlled-trials.com/). Bibliographies of retrieved articles, books, expert opinion review articles and reviewed bibliographies from subject experts were manually searched. Titles and abstracts were screened initially, and potential relevant articles were identified and reviewed. Whenever possible, data were analyzed by comparing IBD patients vs healthy controls, and patients with active IBDs vs those with disease in remission. The effects of IBDs on female fertility, fertility in infertile couples, pregnancy and male infertility were examined separately. Patients with IBDs in remission have normal fertility. At the moment, there is no established guideline for the preservation of fertility in women with IBD undergoing surgery. Further data are needed regarding guidelines for the management of these patients. Data regarding IBDs and infertility are currently completely lacking. Considering the prevalence of intestinal pathology in young adults of childbearing age, this field is of great scientific and clinical interest, opening up important future perspectives. Another important and as yet unexplored point is the response to treatments for infertility in patients with IBDs. In particular, the question is whether the reproductive outcomes (clinical and biological) can be influenced by the IBD of one of the partners. The goals for successful reproductive outcomes in IBD population are correct counseling and disease remission. IBDs significantly affect several reproductive aspects of human (female, male, couple) reproduction. Further data are needed to develop guidelines for the clinical management of subjects of reproductive age with IBDs.

Efficacy of a therapeutic strategy for eradication of Helicobacter pylori infection

AIM: To determine the efficacy of our therapeutic strategy for Helicobacter pylori (H. pylori) eradication and to identify predictive factors for successful eradication.

METHODS: From April 2006 to June 2010, we retrospectively assessed 2428 consecutive patients (1025 men, 1403 women; mean age 55 years, age range 18-92 years) with gastric histology positive for H. pylori infection referred to our unit for 13-C urea breath test (UBT), after first-line therapy with proton pump inhibitor (PPI) b.i.d. + amoxicillin 1 g b.i.d. + clarithromycin 500 mg b.i.d. for 7 d. Patients who were still positive to UBT were recommended a second-line therapy (PPI b.i.d. + amoxicillin 1 g b.i.d. + tinidazole 500 mg b.i.d. for 14 d). Third choice treatment was empirical with PPI b.i.d. + amoxicillin 1 g b.i.d. + levofloxacin 250 mg b.i.d. for 14 d.

RESULTS: Out of 614 patients, still H. pylori-positive after first-line therapy, only 326 and 19 patients respectively rechecked their H. pylori status by UBT after the suggested second and third-line regimens. “Per protocol” eradication rates for first, second and third-line therapy were 74.7% (95% CI: 72.7%-76.4%), 85.3% (95% CI: 81.1%-89.1%) and 89.5% (95% CI: 74.9%-103%) respectively. The overall percentage of patients with H. pylori eradicated after two treatments was 97.8% (95% CI: 97.1%-98.4%), vs 99.9% (95% CI: 99.8%-100%) after three treatments. The study found that eradication therapy was most effective in patients with ulcer disease (P < 0.05, P = 0.028), especially in those with duodenal ulcer. Smoking habits did not significantly affect the eradication rate.

CONCLUSION: First-line therapy with amoxicillin and clarithromycin produces an H. pylori eradication rate comparable or superior to other studies and second-line treatment can still be triple therapy with amoxicillin and tinidazole.

Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps)

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting.

METHODS

We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2-5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months.

RESULTS

We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12-24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively.

CONCLUSIONS

Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.

A randomized clinical trial comparing 22G and 25G needles in endoscopic ultrasound-guided fine-needle aspiration of solid lesions

BACKGROUND AND STUDY AIMS

The study aimed to investigate whether the 25G needle is superior to the 22G needle when used in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of solid lesions.

PATIENTS AND METHODS

The study was a single-center randomized clinical trial. The setting was a tertiary referral hospital, where EUS-FNA of solid lesions was assisted by an on-site cytopathologist, who was blinded to the needle size. The main end point was the number of passes performed to obtain adequate samples. Crossover to the other type of needle was allowed after five passes, or when the gastroenterologist experienced difficulties in puncturing the lesions.

RESULTS

A total of 129 solid lesions were randomized and data regarding 127 lesions were analyzed. The mean number of passes was 3.7 (± 1.9) in the 22G needle group and 3.8 (± 2) in the 25G needle groups (difference of means: 0.1; 95% CI: -0.59 to 0.79). Fifty-eight of 63 (92.1%) and 60/64 samples (93.7%) in the 22G and 25G needle groups respectively were adequate (difference: -1.6%; 95%CI: -12.1% to 8.9%). Crossover to the other type of needle was performed in 11/63 (17.5%) and in 12/64 (18.7%) lesions in the two groups respectively (difference: -1.2%; 95%CI: -16.2% to 13.8%). A crossover to the 25G needle was successfully performed in four masses in the uncinate process; these lesions were difficult to puncture using the 22G needle.

CONCLUSIONS

Our study failed to demonstrate that the 25G is more effective than the 22G needle in EUS-FNA of solid lesions. However, targeting of lesions in the distal duodenum may be simplified by using the 25G needle.

Connections between genetics and clinical data: Role of MCP-1, CFTR, and SPINK-1 in the setting of acute, acute recurrent, and chronic pancreatitis

OBJECTIVES

Acute, acute recurrent, and chronic pancreatitis are inflammatory diseases with multifactorial pathogenic mechanisms. Genetic mutations and polymorphisms have been correlated with pancreatitis. The aim of this study was to investigate the association of cystic fibrosis transmembrane conductance regulator (CFTR) and serine protease inhibitor Kazal type 1 (SPINK-1) gene mutations and monocyte chemoattractant protein 1 (MCP-1) -2518A/G polymorphism with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP), and to associate genetic backgrounds with clinical phenotype in these three conditions.

METHODS

One hundred eighteen AP, 64 ARP, 142 CP patients, and 88 normal controls were enrolled consecutively. We analyzed MCP-1 serum levels using enzyme-linked immunosorbent assay. Polymorphism -2518 of MCP-1 and SPINK-1 N34S gene mutations were determined by PCR-restriction-fragment length polymorphism. Sequence analysis was performed when necessary. Thirty-three CFTR mutations were analyzed in CP and ARP patients using multiplex DNA testing.

RESULTS

Serum MCP-1 levels were significantly higher in all patients affected by pancreatic inflammatory diseases. Moreover, we found a significant over-representation of the MCP-1G allele in ARP patients. We found a statistically significant association of CFTR gene mutations with ARP, but not with CP. We did not find a statistically significant association of ARP or CP with the N34S SPINK-1 gene mutation. Interestingly, 39 of 64 ARP patients (61%) carried at least one genetic mutation and/or polymorphism. Five of 64 ARP patients had pancreas divisum and four of these five also carried the G allele.

CONCLUSIONS

Analysis of a comprehensive range of potential susceptibility variants is needed to support modeling of the effects of genes and environment in pancreatitis. As such, beyond gene mutations, the context within which those mutations exist must be considered. In pancreatitis the context includes the inflammatory response, clinical features, and exogenous factors.

[40 cases of multiple sclerosis treated with hyperbaric oxygen therapy]

40 patients affected by Multiple Sclerosis, all in a worsening phase, have been treated with cicles of HBO since 1979. The therapy consists of a first cycle of dayly treatment (5 in a week) for a total of 10-15 sessions (90' at 2 ATA) and subsequently, according to the case, 3-5 sessions every 1-2 months, or 1 monthly treatment. Six cases did not showed improvements; among these, 4 have received adequate treatment, but in 5 cases the clinical picture do not worsen. The resting 34 cases (85%) had remarkable improvements, complete or near total recovery of one or more symptoms after the first cycle or the following treatments. Improvements or recovery of symptoms can be temporary or permanent along the period of observation (from 3 to 33 months). In 8 subjects the improvement were progressive after successive cycles. Cerebellar, sensorial, and sphincterial symptoms are the most susceptible of positive changes. Walking improvements, hand use normalisation and a better bladder control have allowed many patients a very satisfactory recovery of autonomy.

[Physiopathology of fin swimming. II. Clinical data]

The Authors have carried out a comparative clinical study on the effects caused by the use of several types of fins: with short and soft propeller, long fiber propeller and monofin. The results achieved demonstrate that the use of short fins does not cause any pathogenic effect, while the incidence of inflammatory tendon injuries and of sciatica is remarkable in those persons who employ the other types of fins. Therefore the Authors believe that the use of long and rigid fins or of monofin must be interdict to young people at the age of development in order to avoid the establishment of permanent body's injuries.