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Hagn-Meincke R, Hart PA, Andersen DK, Vege SS, Fogel EL, Serrano J, Bellin MD, Topazian MD, Conwell DL, Li L, Van Den Eeden SK, Drewes AM, Pandol SJ, Forsmark CE, Fisher WE, Yadav D, Olesen SS, Park WG. Circulating immune signatures across clinical stages of chronic pancreatitis: a pilot study. Eur J Gastroenterol Hepatol 2024; 36:177-183. [PMID: 38047728 PMCID: PMC10842751 DOI: 10.1097/meg.0000000000002691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
OBJECTIVE This pilot study seeks to identify serum immune signatures across clinical stages of patients with chronic pancreatitis (CP). METHODS We performed a cross-sectional analysis of prospectively collected serum samples from the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translation StuDies-study. CP subjects were categorised into three clinical stages based on the presence/absence of metabolic complications: (1) CP with no diabetes and exocrine pancreatic dysfunction (EPD), (2) CP with either diabetes or EPD, and (3) CP with diabetes and EPD. Blinded samples were analysed using an 80-plex Luminex assay of cytokines/chemokines/adhesion molecules. Group and pairwise comparisons were performed to characterise immune signatures across CP subgroups. RESULTS A total of 135 CP subjects (evenly distributed between clinical stages) and 50 controls were studied. Interleukin-6 (IL-6), interleukin-8 (IL-8), and soluble intercellular adhesion molecule 1 (sICAM-1) were significantly elevated in CP subjects compared to controls. The levels of IL-6 and IL-8 increased with advancing disease stages, with the highest levels observed in CP with diabetes and EPD (clinical stage 3). Furthermore, hepatocyte growth factor and macrophage-derived chemokine were significantly increased in clinical stage 3 compared to controls. CONCLUSION Our study reveals a progressive elevation in pro-inflammatory cytokines and chemokines with advancing clinical stages of CP. These findings indicate potential targets for the development of disease-modifying interventions.
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Affiliation(s)
- Rasmus Hagn-Meincke
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Melena D Bellin
- Division of Pediatric Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darwin L Conwell
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition. University of Florida, Gainesville, Florida
| | - William E Fisher
- Division of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Walter G Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
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2
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Kaur J, Martin JA, Vege SS, Garimella V, Majumder S, Levy MJ, Abu Dayyeh BK, Storm AC, Vargas EJ, Law RJ, Bofill AM, Decker GA, Petersen BT, Chandrasekhara V. Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis. Dig Dis Sci 2023; 68:4259-4265. [PMID: 37665426 DOI: 10.1007/s10620-023-08004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/13/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) within 72 h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24 h) improved outcomes compared to early ERCP (24-72 h) in patients admitted with predicted mild ABP. METHODS Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72 h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs). RESULTS Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6 mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3 days (IQR 3-4), p < 0.01]. CONCLUSION Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.
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Affiliation(s)
- Jyotroop Kaur
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Vishal Garimella
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Aliana M Bofill
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - G Anton Decker
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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Tirkes T, Yadav D, Conwell DL, Territo PR, Zhao X, Persohn SA, Dasyam AK, Shah ZK, Venkatesh SK, Takahashi N, Wachsman A, Li L, Li Y, Pandol SJ, Park WG, Vege SS, Hart PA, Topazian M, Andersen DK, Fogel EL. Quantitative MRI of chronic pancreatitis: results from a multi-institutional prospective study, magnetic resonance imaging as a non-invasive method for assessment of pancreatic fibrosis (MINIMAP). Abdom Radiol (NY) 2022; 47:3792-3805. [PMID: 36038644 PMCID: PMC9423890 DOI: 10.1007/s00261-022-03654-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE To determine if quantitative MRI techniques can be helpful to evaluate chronic pancreatitis (CP) in a setting of multi-institutional study. METHODS This study included a subgroup of participants (n = 101) enrolled in the Prospective Evaluation of Chronic Pancreatitis for Epidemiologic and Translational Studies (PROCEED) study (NCT03099850) from February 2019 to May 2021. MRI was performed on 1.5 T using Siemens and GE scanners at seven clinical centers across the USA. Quantitative MRI parameters of the pancreas included T1 relaxation time, extracellular volume (ECV) fraction, apparent diffusion coefficient (ADC), and fat signal fraction. We report the diagnostic performance and mean values within the control (n = 50) and CP (n = 51) groups. The T1, ECV and fat signal fraction were combined to generate the quantitative MRI score (Q-MRI). RESULTS There was significantly higher T1 relaxation time; mean 669 ms (± 171) vs. 593 ms (± 82) (p = 0.006), ECV fraction; 40.2% (± 14.7) vs. 30.3% (± 11.9) (p < 0.001), and pancreatic fat signal fraction; 12.2% (± 5.5) vs. 8.2% (± 4.4) (p < 0.001) in the CP group compared to controls. The ADC was similar between groups (p = 0.45). The AUCs for the T1, ECV, and pancreatic fat signal fraction were 0.62, 0.72, and 0.73, respectively. The composite Q-MRI score improved the diagnostic performance (cross-validated AUC: 0.76). CONCLUSION Quantitative MR parameters evaluating the pancreatic parenchyma (T1, ECV fraction, and fat signal fraction) are helpful in the diagnosis of CP. A Q-MRI score that combines these three MR parameters improves diagnostic performance. Further studies are warranted with larger study populations including patients with acute and recurrent acute pancreatitis and longitudinal follow-ups.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine Indianapolis, 550 N. University Blvd. Suite 0663, Indianapolis, IN 46202 USA
| | - Dhiraj Yadav
- Department of Medicine Division of Gastroenterology, Hepatology & Nutrition University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Darwin L. Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY USA
| | - Paul R. Territo
- Division of Clinical Pharmacology, Stark Neurosciences Research Institute Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | - Xuandong Zhao
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | - Scott A. Persohn
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN 46202 USA
| | - Anil K. Dasyam
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Zarine K. Shah
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | | | | | - Ashley Wachsman
- Department of Radiology Cedars-Sinai Medical Center, University of California in Los Angeles, Los Angeles, CA USA
| | - Liang Li
- Department of Biostatistics Director, Quantitative Science Program, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Yan Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Walter G. Park
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA USA
| | - Santhi S. Vege
- Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology & Nutrition The Ohio State University Wexner Medical Center, Columbus, OH USA
| | | | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD USA
| | - Evan L. Fogel
- Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy, Indiana University School of Medicine, Indianapolis, IN USA
| | - On behalf of the Consortium for the Study of Chronic Pancreatitis, Diabetes, Pancreatic Cancer (CPDPC)
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine Indianapolis, 550 N. University Blvd. Suite 0663, Indianapolis, IN 46202 USA
- Department of Medicine Division of Gastroenterology, Hepatology & Nutrition University of Pittsburgh School of Medicine, Pittsburgh, PA USA
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY USA
- Division of Clinical Pharmacology, Stark Neurosciences Research Institute Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN 46202 USA
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH USA
- Department of Radiology, Mayo Clinic, Rochester, MN USA
- Department of Radiology Cedars-Sinai Medical Center, University of California in Los Angeles, Los Angeles, CA USA
- Department of Biostatistics Director, Quantitative Science Program, The University of Texas MD Anderson Cancer Center, Houston, TX USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
- Division of Digestive and Liver Diseases Cedars-Sinai Medical Center, Los Angeles, CA USA
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA USA
- Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
- Division of Gastroenterology, Hepatology & Nutrition The Ohio State University Wexner Medical Center, Columbus, OH USA
- Mayo Clinic, Rochester, MN USA
- Division of Digestive Diseases and Nutrition National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD USA
- Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy, Indiana University School of Medicine, Indianapolis, IN USA
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Chandrasekhara V, Elhanafi S, Storm AC, Takahashi N, Lee NJ, Levy MJ, Kaura K, Wang L, Majumder S, Vege SS, Law RJ, Abu Dayyeh BK. Predicting the Need for Step-Up Therapy After EUS-Guided Drainage of Pancreatic Fluid Collections With Lumen-Apposing Metal Stents. Clin Gastroenterol Hepatol 2021; 19:2192-2198. [PMID: 33965573 DOI: 10.1016/j.cgh.2021.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/12/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A significant proportion of individuals with pancreatic fluid collections (PFCs) require step-up therapy after endoscopic drainage with lumen-apposing metal stents. The aim of this study is to identify factors associated with PFCs that require step-up therapy. METHODS A retrospective cohort study of patients undergoing endoscopic ultrasound-guided drainage of PFCs with lumen-apposing metal stents from April 2014 to October 2019 at a single center was performed. Step-up therapy included direct endoscopic necrosectomy, additional drainage site (endoscopic or percutaneous), or surgical intervention after the initial drainage procedure. Multivariable logistic regression was performed using a backward stepwise approach with a P ≤ .2 threshold for variable retention to identify factors predictive for the need for step-up therapy. RESULTS One hundred thirty-six patients were included in the final study cohort, of whom 69 (50.7%) required step-up therapy. Independent predictors of step-up therapy included: collection size measuring ≥10 cm (odds ratio [OR], 8.91; 95% confidence interval [CI], 3.36-23.61), paracolic extension of the PFC (OR, 4.04; 95% CI, 1.60-10.23), and ≥30% solid necrosis (OR, 4.24; 95% CI, 1.48-12.16). In a sensitivity analysis of 81 patients with walled-off necrosis, 51 (63.0%) required step-up therapy. Similarly, factors predictive of the need for step-up therapy for walled-off necrosis included: collection size measuring ≥10 cm (OR, 6.94; 95% CI, 1.76-27.45), paracolic extension of the PFC (OR, 3.79; 95% CI, 1.18-12.14), and ≥30% solid necrosis (OR, 7.10; 95% CI, 1.16-43.48). CONCLUSIONS Half of all patients with PFCs drained with lumen-apposing metal stents required step-up therapy, most commonly direct endoscopic necrosectomy. Individuals with PFCs ≥10 cm in size, paracolic extension, or ≥30% solid necrosis are more likely to require step-up therapy and should be considered for early endoscopic reintervention.
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Affiliation(s)
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Nam Ju Lee
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karan Kaura
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina
| | - Lillian Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ryan J Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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5
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Bergquist JR, Thiels CA, Shubert CR, Ivanics T, Habermann EB, Vege SS, Grotz TE, Cleary SP, Smoot RL, Kendrick ML, Nagorney DM, Truty MJ. Perception versus reality: A National Cohort Analysis of the surgery-first approach for resectable pancreatic cancer. Cancer Med 2021; 10:5925-5935. [PMID: 34289264 PMCID: PMC8419760 DOI: 10.1002/cam4.4144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Although surgical resection is necessary, it is not sufficient for long‐term survival in pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate survival after up‐front surgery (UFS) in anatomically resectable PDAC in the context of three critical factors: (A) margin status; (B) CA19‐9; and (C) receipt of adjuvant chemotherapy. Methods The National Cancer Data Base (2010–2015) was reviewed for clinically resectable (stage 0/I/II) PDAC patients. Surgical margins, pre‐operative CA19‐9, and receipt of adjuvant chemotherapy were evaluated. Patient overall survival was stratified based on these factors and their respective combinations. Outcomes after UFS were compared to equivalently staged patients after neoadjuvant chemotherapy on an intention‐to‐treat (ITT) basis. Results Twelve thousand and eighty‐nine patients were included (n = 9197 UFS, n = 2892 ITT neoadjuvant). In the UFS cohort, only 20.4% had all three factors (median OS = 31.2 months). Nearly 1/3rd (32.7%) of UFS patients had none or only one factor with concomitant worst survival (median OS = 14.7 months). Survival after UFS decreased with each failing factor (two factors: 23 months, one factor: 15.5 months, no factors: 7.9 months) and this persisted after adjustment. Overall survival was superior in the ITT‐neoadjuvant cohort (27.9 vs. 22 months) to UFS. Conclusion Despite the perceived benefit of UFS, only 1‐in‐5 UFS patients actually realize maximal survival when known factors highly associated with outcomes are assessed. Patients are proportionally more likely to do worst, rather than best after UFS treatment. Similarly staged patients undergoing ITT‐neoadjuvant therapy achieve survival superior to the majority of UFS patients. Patients and providers should be aware of the false perception of ‘optimal’ survival benefit with UFS in anatomically resectable PDAC.
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Affiliation(s)
- John R Bergquist
- Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, Palo Alto, California, USA.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Christopher R Shubert
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Hepatopancreatobiliary Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tommy Ivanics
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Santhi S Vege
- Mayo Clinic Rochester, Department of Medicine, Division of Gastroenterology, Pancreatology Section, Rochester, Minnesota, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
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6
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Marya NB, Powers PD, Chari ST, Gleeson FC, Leggett CL, Abu Dayyeh BK, Chandrasekhara V, Iyer PG, Majumder S, Pearson RK, Petersen BT, Rajan E, Sawas T, Storm AC, Vege SS, Chen S, Long Z, Hough DM, Mara K, Levy MJ. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut 2021; 70:1335-1344. [PMID: 33028668 DOI: 10.1136/gutjnl-2020-322821] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time. DESIGN A database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC. RESULTS From 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP). CONCLUSION The developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.
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Affiliation(s)
- Neil B Marya
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Suresh T Chari
- Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ferga C Gleeson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarek Sawas
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shigao Chen
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zaiyang Long
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Hough
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin Mara
- Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Wang L, Elhanafi S, Storm AC, Topazian MD, Majumder S, Abu Dayyeh BK, Levy MJ, Petersen BT, Martin JA, Chari ST, Vege SS, Chandrasekhara V. Impact of disconnected pancreatic duct syndrome on endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endoscopy 2021; 53:603-610. [PMID: 32629484 DOI: 10.1055/a-1213-1489] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic intervention for pancreatic fluid collections (PFCs) with disconnected pancreatic duct syndrome (DPDS) has been associated with failures and increased need for additional endoscopic and non-endoscopic interventions. The primary aim of this study was to determine the outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of PFCs in patients with DPDS. METHODS In patients undergoing EUS-guided drainage of PFCs from January 2013 to January 2018, demographic profiles, procedural indications and details, adverse events, outcomes, and subsequent interventions were retrospectively collected. Overall treatment success was determined by PFC resolution on follow-up imaging or stent removal without recurrence. RESULTS EUS-guided drainage of PFCs was performed in 141 patients. DPDS was present in 57 of them (40 %) and walled-off necrosis was the most frequent type of PFC (55 %). DPDS was not associated with lower clinical success, increased number of repeat interventions, or increased time to PFC resolution. Patients with DPDS were more likely to be treated with permanent transmural plastic double-pigtail stents (odds ratio [OR] 6.4; 95 % confidence interval [CI] 2.5 - 16.5; P < 0.001). However, when stents were removed, DPDS was associated with increased PFC recurrence after stent removal (OR 8.0; 95 %CI 1.2 - 381.8; P = 0.04). CONCLUSIONS DPDS frequently occurs in patients with PFCs but does not negatively impact successful resolution. DPDS is associated with increased PFC recurrence after stent removal.
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Affiliation(s)
- Lillian Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic at Rochester, Rochester, Minnesota, USA
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8
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Levy MJ, Gleeson FC, Topazian MD, Fujii-Lau LL, Enders FT, Larson JJ, Mara K, Abu Dayyeh BK, Alberts SR, Hallemeier CL, Iyer PG, Kendrick ML, Mauck WD, Pearson RK, Petersen BT, Rajan E, Takahashi N, Vege SS, Wang KK, Chari ST. Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone. Clin Gastroenterol Hepatol 2019; 17:728-738.e9. [PMID: 30217513 DOI: 10.1016/j.cgh.2018.08.040] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival. METHODS We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events. RESULTS Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques. CONCLUSION In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kristin Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - William D Mauck
- Department of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
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9
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Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN, Falck-Ytter Y, Feuerstein J, Flamm S, Gellad Z, Gerson L, Gupta S, Hirano I, Inadomi J, Nguyen GC, Rubenstein JH, Singh S, Smalley WE, Stollman N, Street S, Sultan S, Vege SS, Wani SB, Weinberg D. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology 2018; 154:1096-1101. [PMID: 29409760 DOI: 10.1053/j.gastro.2018.01.032] [Citation(s) in RCA: 437] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Yngve Falck-Ytter
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio; Louis Stokes VA Medical Center, Cleveland, Ohio
| | - Alan N Barkun
- Division of Gastroenterology, McGill University, Montréal, Québec, Canada
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10
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Abu Dayyeh BK, Mukewar S, Majumder S, Zaghlol R, Vargas Valls EJ, Bazerbachi F, Levy MJ, Baron TH, Gostout CJ, Petersen BT, Martin J, Gleeson FC, Pearson RK, Chari ST, Vege SS, Topazian MD. Large-caliber metal stents versus plastic stents for the management of pancreatic walled-off necrosis. Gastrointest Endosc 2018; 87:141-149. [PMID: 28478030 DOI: 10.1016/j.gie.2017.04.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Symptomatic pancreatic walled-off necrosis (WON) may be managed by endoscopic transmural drainage and endoscopic transmural necrosectomy, with stent placement at endoscopic drainage sites. The optimal stent choice is yet to be determined. We compared outcomes after endoscopic management of WON using either large-caliber fully covered self-expandable metal stents (LC-SEMSs) or double-pigtail plastic stents (DPPSs). METHODS We performed a retrospective comparison of outcomes among patients who received LC-SEMSs or DPPSs before endoscopic transmural necrosectomy for WON. RESULTS Among 94 patients included, WON resolution rates did not differ between the DPPS (36 patients) and LC-SEMS (58 patients) groups, whether concomitant percutaneous drainage was considered a failure (75% vs 82.8%; P = .36) or not (91.7% vs 94.8%; P = .55). Of 75 patients (80%) successfully treated without percutaneous drainage, 37 (49%) underwent endoscopic transmural drainage without subsequent endoscopic transmural necrosectomy. WON was more likely to resolve without subsequent endoscopic transmural necrosectomy in the LC-SEMS group than the DPPS group (60.4% vs 30.8%; P = .01). WON resolution without subsequent endoscopic transmural necrosectomy remained more likely with LC-SEMSs (odds ratio, 4.5 [95% confidence interval, 1.5-15.5]) after adjusting for patient age and size and location of WON. Rates of adverse events were similar except for clinically significant bleeding requiring endoscopic intervention, which was higher with DPPSs than LC-SEMSs (14% vs 2%; P = .02). CONCLUSION Management of pancreatic WON with LC-SEMSs appears to decrease both the need for repeated necrosectomy procedures and the risk of intervention-related hemorrhage.
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Affiliation(s)
- Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raja Zaghlol
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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11
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Mukewar S, de Pretis N, Aryal-Khanal A, Ahmed N, Sah R, Enders F, Larson JJ, Levy MJ, Takahashi N, Topazian M, Pearson R, Vege SS, Chari ST. Fukuoka criteria accurately predict risk for adverse outcomes during follow-up of pancreatic cysts presumed to be intraductal papillary mucinous neoplasms. Gut 2017; 66:1811-1817. [PMID: 27390303 PMCID: PMC7597030 DOI: 10.1136/gutjnl-2016-311615] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Fukuoka consensus guidelines classify pancreatic cystic lesions (PCLs) presumed to be intraductal papillary mucinous neoplasms (IPMNs) into Fukuoka positive (FP) (subgroups of high-risk (HR) and worrisome features (WFs)) and Fukuoka negative (FN) (non-HR feature/WF cysts). We retrospectively estimated 5-year risk of pancreatic cancer (PC) in FN, WF and HR cysts of patients with PCL-IPMN. DESIGN From Mayo Clinic databases, we randomly selected 2000 patients reported to have a PCL; we excluded inflammatory or suspected non-IPMN cysts and those without imaging follow-up. We re-reviewed cross-sectional imaging and abstracted clinical and follow-up data on PCL-IPMNs. The study contained 802 patients with FN cysts and 358 with FP cysts. RESULTS Patients with PCL-IPMN had median (IQR) follow-up of 4.2 (1.8-7.1) years. Among FN cysts, 5-year PC risk was low (2-3%) regardless of cyst size (p=0.67). After excluding events in the first 6 months, 5-year PC risk remained low (0-2%) regardless of cyst size (p=0.61). Among FP cysts, HR cysts (n=66) had greater 5-year PC risk than WF cysts (n=292) (49.7% vs 4.1%; p<0.001). In HR cysts, 3-year PC risk was greatest for obstructive jaundice versus enhancing solid component or main pancreatic duct >10 mm (79.8% vs 37.3% vs 39.4%, respectively; p=0.01). CONCLUSIONS Fukuoka guidelines accurately stratify PCL-IPMNs for PC risk, with FN cysts having lowest and HR cysts having greatest risk. After 6-month follow-up, WF and FN cysts had a low 5-year PC risk. Surveillance strategies should be tailored appropriately.
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Affiliation(s)
- Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicolo de Pretis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anupama Aryal-Khanal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nazir Ahmed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raghuwansh Sah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Felicity Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Feuerstein JD, Nguyen GC, Kupfer SS, Falck-Ytter Y, Singh S, Hirano I, Nguyen GC, Rubenstein JH, Smalley WE, Stollman N, Sultan S, Vege SS, Wani SB, Weinberg D, Yang YX. American Gastroenterological Association Institute Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease. Gastroenterology 2017; 153:827-834. [PMID: 28780013 DOI: 10.1053/j.gastro.2017.07.032] [Citation(s) in RCA: 389] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Joseph D Feuerstein
- Division of Gastroenterology and Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
| | - Sonia S Kupfer
- Division of Gastroenterology, The University of Chicago, Chicago, Illinois
| | - Yngve Falck-Ytter
- Division of Gastroenterology and Liver Disease, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Siddharth Singh
- Division of Gastroenterology, University of California, San Diego, La Jolla, California
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13
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Rustagi T, Gleeson FC, Chari ST, Abu Dayyeh BK, Farnell MB, Iyer PG, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Truty MJ, Vege SS, Wang KK, Levy MJ. Remote malignant intravascular thrombi: EUS-guided FNA diagnosis and impact on cancer staging. Gastrointest Endosc 2017; 86:150-155. [PMID: 27773725 DOI: 10.1016/j.gie.2016.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Malignant vascular invasion usually results from gross direct infiltration from a primary tumor and impacts cancer staging, prognosis, and therapy. However, patients may also develop a remote malignant thrombi (RMT), defined as a malignant intravascular thrombus located remote and noncontiguous to the primary tumor. Our aim was to compare EUS, CT, and magnetic resonance imaging (MRI) findings of RMT and to explore the potential impact on cancer staging. METHODS Patients with RMT were identified from a prospectively maintained EUS database. Retrospective chart review was performed to obtain EUS, CT/MRI, clinical, and outcome data. RESULTS A median of 3 FNAs (range, 1-8) was obtained from RMT in 17 patients (60 ± 14.1 years, 56% men) between April 2003 and August 2016, with the finding of malignant cytology in 12 patients (70.6%; 10 positive, 2 suspicious). CT/MRI detected the RMT in 5 patients (29.4%), 4 of whom had positive or suspicious EUS-FNA cytology. Among the 8 newly diagnosed pancreatic adenocarcinoma (PaC) patients, CT did not detect the RMT in 5 (63%), of whom 3 patients had positive or suspicious intravascular EUS-FNA cytology. For newly diagnosed PaC patients (n = 8), the EUS-FNA diagnosis of a biopsy specimen-proven RMT upstaged 3 patients (37.5%) and converted 2 patients (25%) from CT resectable to unresectable disease. No adverse events were reported. The mean follow-up was 18.9 ± 27.7 months. CONCLUSIONS Our study demonstrates the ability and potential safety of intravascular FNA to detect radiographically occult RMT, which substantially impacts cancer staging and resectability.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Randall K Pearson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Rustagi T, Gleeson FC, Chari ST, Abu Dayyeh BK, Farnell MB, Iyer PG, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Truty MJ, Vege SS, Wang KK, Levy MJ. Endoscopic Ultrasound Fine-Needle Aspiration Diagnosis of Synchronous Primary Pancreatic Adenocarcinoma and Effects on Staging and Resectability. Clin Gastroenterol Hepatol 2017; 15:299-302.e4. [PMID: 27539084 DOI: 10.1016/j.cgh.2016.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 12/13/2022]
Abstract
Synchronous primary pancreatic adenocarcinoma, defined as the simultaneous presence of 2 or more newly identified and anatomically separate primary adenocarcinomas within the pancreas, is reported rarely. We compared endoscopic ultrasound (EUS) and computed tomography (CT) and magnetic resonance imaging (MRI) findings from patients with synchronous primary pancreatic adenocarcinoma and their effects on cancer staging and treatment. We performed a retrospective analysis of the EUS database at the Mayo Clinic, from September 2008 through May 2016, to collect EUS, CT, MRI, and clinical data from patients with synchronous primary pancreatic adenocarcinoma. EUS and separate fine-needle aspiration of both tumors detected synchronous primary pancreatic adenocarcinoma in 11 patients (70.9 ± 10.4 y; 64% men). Of the 22 cancers, CT (n = 9) and MRI (n = 2) detected 9 (41%) cancers; in only 2 patients did CT detect both cancers. EUS increased cancer stage for 7 of the 11 (64%) patients and changed the status from resectable to unresectable for 3 of the 9 (33%) patients, compared with CT or MRI. EUS findings altered the likely extent of surgical resection for 3 patients. Synchronous primary pancreatic adenocarcinoma is reported rarely and may be undetected by CT or MRI; this could account for the false presumption of early tumor recurrence, rather than actual residual second tumor, leading to incomplete resection.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
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15
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Hart PA, Levy MJ, Smyrk TC, Takahashi N, Abu Dayyeh BK, Clain JE, Gleeson FC, Pearson RK, Petersen BT, Topazian MD, Vege SS, Zhang L, Chari ST. Clinical profiles and outcomes in idiopathic duct-centric chronic pancreatitis (type 2 autoimmune pancreatitis): the Mayo Clinic experience. Gut 2016; 65:1702-9. [PMID: 26085439 DOI: 10.1136/gutjnl-2015-309275] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/28/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Idiopathic duct-centric chronic pancreatitis (IDCP), also known as type 2 autoimmune pancreatitis (AIP), is an uncommon subtype of AIP. International Consensus Diagnostic Criteria for IDCP propose that the diagnosis requires pancreatic histology and/or concurrent IBD. We examined our experience with IDCP (type 2 AIP) to assess the appropriateness of these criteria, and identify unique characteristics in patients presenting with acute pancreatitis. DESIGN We reviewed the Mayo Clinic AIP database through May 2014 to identify subjects with either definitive (n=31) or probable (n=12) IDCP. We compared demographic and clinical factors based on strength of diagnostic confidence (definitive versus probable), presence of IBD, and acute pancreatitis as the presenting manifestation. Relapse-free survival was determined using the Kaplan-Meier method. RESULTS The clinical profiles were similar irrespective of the diagnostic criteria fulfilled. Common clinical presentations included acute pancreatitis (n=25, 58.1%, 12 of whom (27.9%) had recurrent pancreatitis) and pancreatic mass/obstructive jaundice (n=15, 34.9%). The cumulative relapse rate was 10.6% at 3 years (median follow-up 2.9 years). Relapse-free survival was similar for the different diagnostic categories, but was decreased in those initially presenting with acute pancreatitis (p=0.047) or treated with steroids (vs surgery, p=0.049). CONCLUSIONS The current diagnostic classification of probable IDCP and the inclusion of IBD as a supportive criterion appear valid, because patients have similar clinical profiles and disease-related outcomes to those with definitive IDCP. Concurrent IBD, especially in young patients, may suggest when IDCP is the underlying cause of recurrent acute pancreatitis, but additional studies are needed for validation.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas C Smyrk
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan E Clain
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Abstract
PURPOSE OF REVIEW To summarize recent data on classification systems, cause, risk factors, severity prediction, nutrition, and drug treatment of acute pancreatitis. RECENT FINDINGS Comparison of the Revised Atlanta Classification and Determinant Based Classification has shown heterogeneous results. Simvastatin has a protective effect against acute pancreatitis. Young black male, alcohol, smoldering symptoms, and subsequent diagnosis of chronic pancreatitis are risk factors associated with readmissions after acute pancreatitis. A reliable clinical or laboratory marker or a scoring system to predict severity is lacking. The PYTHON trial has shown that oral feeding with on demand nasoenteric tube feeding after 72 h is as good as nasoenteric tube feeding within 24 h in preventing infections in predicted severe acute pancreatitis. Male sex, multiple organ failure, extent of pancreatic necrosis, and heterogeneous collection are factors associated with failure of percutaneous drainage of pancreatic collections. SUMMARY The newly proposed classification systems of acute pancreatitis need to be evaluated more critically. New biomarkers are needed for severity prediction. Further well designed studies are required to assess the type of enteral nutritional formulations for acute pancreatitis. The optimal minimally invasive method or combination to debride the necrotic collections is evolving. There is a great need for a drug to treat the disease early on to prevent morbidity and mortality.
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Affiliation(s)
- Rupjyoti Talukdar
- aAsian Institute of Gastroenterology/Asian Healthcare Foundation, Hyderabad, Telangana, India bDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Fujii-Lau LL, Bamlet WR, Eldrige JS, Chari ST, Gleeson FC, Abu Dayyeh BK, Clain JE, Pearson RK, Petersen BT, Rajan E, Topazian MD, Vege SS, Wang KK, Wiersema MJ, Levy MJ. Impact of celiac neurolysis on survival in patients with pancreatic cancer. Gastrointest Endosc 2015; 82:46-56.e2. [PMID: 25800661 PMCID: PMC6017988 DOI: 10.1016/j.gie.2014.12.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) often produces pain that is difficult to control. Celiac neurolysis (CN) is performed with the goal of improving pain control and quality of life while reducing opioid-related side effects. OBJECTIVE We aimed to evaluate whether CN provides a survival advantage for PC patients. DESIGN Retrospective case-control study. SETTING Single tertiary-care referral center. PATIENTS Review of a prospectively maintained database identified patients with unresectable PC who underwent CN over a 12-year period. Each patient was matched to 2 control patients with unresectable PC. INTERVENTION CN, which included both celiac plexus neurolysis (CPN) and celiac ganglia neurolysis (CGN). MAIN OUTCOME MEASUREMENTS Median survival in Kaplan-Meier curves and hazard ratios. RESULTS A total of 417 patients underwent CN and were compared with 840 controls with PC. Baseline characteristics were similar except the CN group had greater weight loss and pain requiring opioids. A mean of 16.6 ± 5.8 mL of alcohol was administered. For patients who underwent CN, the median survival from the time of presentation was shorter compared with controls (193 vs 246 days; hazard ratio 1.32; 95% confidence interval, 1.13-1.54). There was no difference in survival with unilateral or bilateral injection. However, EUS-guided CN was associated with longer survival compared with non-EUS approaches, and those who received CPN had longer survival compared with CGN. LIMITATIONS Single center, retrospective. CONCLUSION Our study suggests that CN is an independent predictor of shortened survival in PC patients. A prospective study is needed to verify the findings and determine whether shortened survival results from CN or from other features such as performance status and tumor-related characteristics. It is also imperative to verify our finding that EUS-guided CN provides a survival advantage over other approaches and whether CPN prolongs survival compared with CGN.
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Ngwa TN, Beyder A, Vege SS. 84-year-old man with night sweats, weight loss, and diarrhea. Mayo Clin Proc 2014; 89:409-13. [PMID: 24582198 DOI: 10.1016/j.mayocp.2013.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 04/24/2013] [Accepted: 05/08/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Taiwo N Ngwa
- Resident in Internal Medicine, Mayo Graduate School of Medical Education, Rochester, MN
| | - Arthur Beyder
- Fellow in Gastroenterology and Hepatology, Mayo Graduate School of Medical Education, Rochester, MN
| | - Santhi S Vege
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Fujii LL, Topazian MD, Abu Dayyeh BK, Baron TH, Chari ST, Farnell MB, Gleeson FC, Gostout CJ, Kendrick ML, Pearson RK, Petersen BT, Truty MJ, Vege SS, Levy MJ. EUS-guided pancreatic duct intervention: outcomes of a single tertiary-care referral center experience. Gastrointest Endosc 2013; 78:854-864.e1. [PMID: 23891418 DOI: 10.1016/j.gie.2013.05.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/09/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS can provide access to the main pancreatic duct (MPD) for therapeutic intervention. The long-term clinical success of EUS-guided MPD interventions is unknown. OBJECTIVE To determine technical and clinical success rates, predictors of success, and long-term outcomes of EUS-guided MPD intervention. DESIGN Retrospective, single-center study. SETTING Tertiary-care referral center. PATIENTS Forty-five patients. INTERVENTION EUS-guided MPD stent retrieval or placement. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates, adverse events, and long-term clinical outcomes. RESULTS Among the 45 patients, 37 had undergone failed ERCP, and 29 had surgically altered anatomy. Median follow-up after initial EUS-guided intervention was 23 months. Two patients underwent EUS for stent removal, and EUS-guided MPD stent placement was attempted in 43 patients. Technical success was achieved in 32 of 43 patients (74%) with antegrade (n = 18) or retrograde (n = 14) stent insertion. Serious adverse events occurred in 3 patients (6%). Patients underwent a median of 2 (range 1-6) follow-up procedures for revision or removal of stents, without adverse events. Complete symptom resolution occurred in 24 of 29 patients (83%) while stents were in place, including all 6 with nondilated ducts. Stents were removed in 23 patients, who were then followed for an additional median of 32 months; 4 patients had recurrent symptoms. Among the 11 failed cases, most had persistent symptoms or required surgery. LIMITATIONS Retrospective study design, individualized patient management. CONCLUSION EUS-guided MPD intervention is feasible and safe, with long-term clinical success in the majority of patients. EUS provides important treatment options, particularly in patients who would otherwise undergo surgery.
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Affiliation(s)
- Larissa L Fujii
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael B Farnell
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Christopher J Gostout
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Hart PA, Topazian MD, Witzig TE, Clain JE, Gleeson FC, Klebig RR, Levy MJ, Pearson RK, Petersen BT, Smyrk TC, Sugumar A, Takahashi N, Vege SS, Chari ST. Treatment of relapsing autoimmune pancreatitis with immunomodulators and rituximab: the Mayo Clinic experience. Gut 2013; 62:1607-15. [PMID: 22936672 DOI: 10.1136/gutjnl-2012-302886] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a paucity of data on long-term management of type 1 autoimmune pancreatitis (AIP), a relapsing steroid-responsive disorder. OBJECTIVE We describe our experience with treatment of relapses and maintenance of remission using steroid-sparing immunomodulators (IMs) and induction of remission using rituximab (RTX). METHODS We obtained details of disease relapse and treatment in 116 type 1 AIP patients from clinic visits, medical records and telephone interviews. We compared relapse free survival in those treated with IMs versus those treated with steroids alone, assessed patients' response to RTX, and identified treatment-related complications. RESULTS During a median follow-up of 47 months, 52/116 AIP patients experienced 76 relapse episodes. The first relapse was treated with another course of steroids in 24 patients, and with steroids plus IM in another 27 patients; subsequent relapse-free survival until a second relapse was similar in the two groups (p=0.23). 38 patients received an IM for >2 months; failure or intolerance of IM therapy occurred in 17 (45%). 12 patients with steroid or IM intolerance/resistance were treated with RTX, an antiCD20 antibody; 10 (83%) experienced complete remission and had no relapses while on maintenance therapy. Treatment-limiting side effects related to RTX were uncommon. CONCLUSIONS In type 1 AIP relapses are common. Relapse-free survival is similar in those treated with steroids plus IM compared to those treated with steroids alone. Nearly half the patients on IMs will relapse during treatment. RTX is effective in the treatment of both IM resistant and steroid intolerant patients.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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21
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Ferrara MJ, Lohse C, Kudva YC, Farnell MB, Que FG, Reid-Lombardo KM, Donohue JH, Nagorney DM, Chari ST, Vege SS, Kendrick ML. Immediate post-resection diabetes mellitus after pancreaticoduodenectomy: incidence and risk factors. HPB (Oxford) 2013; 15:170-4. [PMID: 23374356 PMCID: PMC3572276 DOI: 10.1111/j.1477-2574.2012.00520.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND New-onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post-resection diabetes mellitus (iPRDM). METHODS Retrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post-resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post-operatively. Logistic regression was conducted to identify factors predictive of iPRDM. RESULTS Of 778 patients undergoing PD, 214 were excluded owing to pre-operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre-operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre-operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre-operative impaired glucose intolerance (P < 0.001), pre-operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c-index of 0.842. DISCUSSION New-onset, post-resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre-operative glucose intolerance, elevated pre-operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD.
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Affiliation(s)
| | - Christine Lohse
- Department of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, MI, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Mayo Clinic Rochester, Rochester, MI, USA
| | | | - Florencia G. Que
- Department of Surgery, Mayo Clinic Rochester, Rochester, MI, USA
| | | | - John H. Donohue
- Department of Surgery, Mayo Clinic Rochester, Rochester, MI, USA
| | | | - Suresh T. Chari
- Division of Gastroenterology, Mayo Clinic Rochester, Rochester, MI, USA
| | - Santhi S. Vege
- Division of Gastroenterology, Mayo Clinic Rochester, Rochester, MI, USA
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22
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Balasubramanian G, Sugumar A, Smyrk TC, Takahashi N, Clain JE, Gleeson FC, Hart PA, Levy MJ, Pearson RK, Petersen BT, Topazian MD, Vege SS, Chari ST. Demystifying seronegative autoimmune pancreatitis. Pancreatology 2012; 12:289-94. [PMID: 22898628 DOI: 10.1016/j.pan.2012.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/02/2012] [Accepted: 05/05/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) has been classified into type 1 and type 2 subtypes. Serum immunoglobulin G4 (IgG4) elevation characterizes type 1 AIP. Type 2 AIP and a subset of type 1 AIP are seronegative, i.e., have normal serum IgG4 levels. AIM We compared the profiles of the three subsets of AIP to identify the unique characteristics of seronegative type 1 AIP and type 2 AIP. METHODS We compared the clinical profiles of 69 seropositive type 1 AIP patients, 21 seronegative type 1 AIP patients and 22 type 2 AIP patients. RESULTS Among type 1 AIP, seronegative group had similar clinical profiles when compared to seropositive group except that they were more likely to undergo surgical resection than seropositive patients (p = 0.001). Seronegative type I AIP patients were older (61.9 ± 13.7 vs 45.3 ± 17.4; p = 0.004), and differed in the occurrence of other organ involvement (OOI) (71.4% vs 0%; p < 0.001) and disease relapse (33.3% vs 0%; p = 0.005) when compared with type 2 AIP. All seronegative type 1 AIP patients had at least one of the following -OOI, disease relapse, and age >50 years while none of the type 2 AIP had OOI or disease relapse. CONCLUSIONS Seronegative and seropositive type 1 AIP patients have similar clinical profiles, which are distinct from that of type 2 AIP. Among the seronegative AIP group, patients are more likely to have type 1 AIP rather than type 2 AIP if they are older than 50 years or have OOI or disease relapse.
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Affiliation(s)
- Gokulakrishnan Balasubramanian
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic 200 First Street SW, Rochester, Minnesota 55905, USA
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Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the main pancreatic duct is usually treated by surgical excision of the affected pancreas. Nonoperative ablative therapies have not been described. We treated IPMN of the pancreatic duct with photodynamic therapy (PDT) in a patient who was a poor operative candidate. Porfimer sodium was administered intravenously, and laser light was delivered by a diffusing catheter placed in the pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP). Imaging and biopsy findings of IPMN resolved after PDT, and symptoms also resolved. Metastatic cancer was diagnosed 2 years after PDT had been initiated. Pancreatic PDT was well tolerated in this case, and may be a therapeutic option for selected patients with IPMN of the main pancreatic duct.
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Affiliation(s)
- M Topazian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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24
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Zhong N, Topazian M, Petersen BT, Baron TH, Chari ST, Gleeson FC, Levy MJ, Kendrick ML, Vege SS. Endoscopic drainage of pancreatic fluid collections into fourth portion of duodenum: a new approach to disconnected pancreatic duct syndrome. Endoscopy 2011; 43 Suppl 2 UCTN:E45-6. [PMID: 21287446 DOI: 10.1055/s-0030-1255902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- N Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong, China
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25
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Leise MD, Smyrk TC, Takahashi N, Sweetser SR, Vege SS, Chari ST. IgG4-associated cholecystitis: another clue in the diagnosis of autoimmune pancreatitis. Dig Dis Sci 2011; 56:1290-4. [PMID: 21082348 DOI: 10.1007/s10620-010-1478-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Accepted: 10/26/2010] [Indexed: 12/24/2022]
Abstract
PURPOSE Autoimmune pancreatitis (AIP) is the pancreatic manifestation of IgG4-associated systemic disease (ISD). Criteria for diagnosis of AIP include recognition of extra-pancreatic organ involvement. Because the diagnosis of AIP can be challenging, even for experts, it is important for clinicians to recognize other target organ damage in this disease. Typical gallbladder findings in AIP have been increasingly recognized. Because cholecystectomy is common in the community, the availability of previous tissue from the gallbladder can provide an important supportive clue in the diagnosis of AIP. The objective of this review is to examine the literature on common gallbladder pathology findings in AIP, and discuss their clinical utility. RESULTS Gallbladder involvement in AIP seems to be common. Transmural lymphoplasmacytic inflammatory infiltrates, extramural inflammatory nodules, the presence of tissue eosinophilia, phlebitis, and increased tissue IgG4 are all seen more frequently in the gallbladders of patients with AIP. These findings are not 100% specific, because some can be seen in primary sclerosing cholangitis and pancreatic adenocarcinoma. CONCLUSION Cholecystectomy for the purpose of diagnosing AIP is not recommended. However, if gallbladder specimens from a previous cholecystectomy are available, an expert review of gallbladder slides with IgG4 immunostaining may help to provide additional criteria for diagnosis of autoimmune pancreatitis.
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Affiliation(s)
- Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Gonda Building 9th Floor, 200 First Street SW, Rochester, MN 55905, USA
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26
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Park WGU, Mascarenhas R, Palaez-Luna M, Smyrk TC, O'Kane D, Clain JE, Levy MJ, Pearson RK, Petersen BT, Topazian MD, Vege SS, Chari ST. Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts. Pancreas 2011; 40:42-5. [PMID: 20966811 PMCID: PMC3005131 DOI: 10.1097/mpa.0b013e3181f69f36] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate and validate cyst fluid carcinoembyronic antigen (CEA) and amylase in differentiating (1) nonmucinous from mucinous pancreatic cystic lesions (PCLs), (2) benign mucinous from malignant mucinous PCLs, and (3) pseudocysts from nonpseudocysts (amylase only). METHODS A retrospective analysis of patients with histologically confirmed PCLs from February 1996 to April 2007 was performed. Cyst fluid CEA (n=124) and/or amylase (n=91) were measured and correlated to cyst type. RESULTS Carcinoembyronic antigen levels (P=0.0001), but not amylase, were higher in mucinous versus nonmucinous cysts. The sensitivity, specificity, and diagnostic accuracy of CEA 200 ng/mL or greater for the diagnosis of mucinous PCLs were 60%, 93%, and 72%, respectively. Carcinoembyronic antigen levels did not differentiate benign from malignant mucinous cysts. Whereas amylase levels were higher in pseudocysts than nonpseudocysts (P=0.009), 54% of noninflammatory PCLs had a level greater than 250 IU/L, including mucinous cystic neoplasms (median, 6800 IU/L; interquartile range, 70-25,295 IU/L). Malignant mucinous cysts had lower amylase levels than benign mucinous cysts (P=0.0008). CONCLUSIONS Cyst fluid CEA and amylase levels are suggestive but not diagnostic in differentiating PCLs. Unlike CEA, amylase may help differentiate benign from malignant mucinous cysts. Novel biomarkers are needed.
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Affiliation(s)
- Walter Gwang-Up Park
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Parsaik AK, Murad MH, Sathananthan A, Moorthy V, Erwin PJ, Chari S, Carter RE, Farnell MB, Vege SS, Sarr MG, Kudva YC. Metabolic and target organ outcomes after total pancreatectomy: Mayo Clinic experience and meta-analysis of the literature. Clin Endocrinol (Oxf) 2010; 73:723-31. [PMID: 20681992 DOI: 10.1111/j.1365-2265.2010.03860.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Total pancreatectomy (TP) has been associated with substantial metabolic abnormalities and poor glycaemic control limiting its use. Because data reported to date are limited, we evaluated outcomes related to the diabetes mellitus obligated by TP. METHODS A case series study of all patients who underwent TP from 01/01/1985 to 12/31/2006 at Mayo Clinic was conducted. TP cases were summarized according to perioperative procedures, mortality and morbidity after TP. To complement this retrospective examination, a survey was developed to measure DM treatment modality, target organ failure and complications in patients alive in 2007. We performed a meta-analysis to compare our results with similar previous studies and provide overall estimates of outcomes. RESULTS A total of 141 cases were studied (97 malignant diseases, 44 benign diseases). The median survival was much less for malignant pathology (2·2 vs 8·7 years, Log rank P = 0·0009). In 2007, there were 59 patients that were presumed alive and 47 (80%) responded to the survey. Mean HbA1c at last follow-up was 7·5% with 89% of respondents on a complex insulin programme (mean daily insulin requirement 35 ± 13 units). Episodic hypoglycaemia was experienced by 37 (79%); 15 (41%) experienced severe hypoglycaemia. In contrast, diabetic ketoacidosis developed in only 2 (4%). Target organ complications and chronic diarrhoea developed in 13 patients (28%) each. CONCLUSION The primary factor determining survival after TP is the aetiology necessitating TP, i.e. pancreatic malignancy. Most respondents used complex insulin programmes, but hypoglycaemia continues to be a problem.
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28
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Sah RP, Chari ST, Pannala R, Sugumar A, Clain JE, Levy MJ, Pearson RK, Smyrk TC, Petersen BT, Topazian MD, Takahashi N, Farnell MB, Vege SS. Differences in clinical profile and relapse rate of type 1 versus type 2 autoimmune pancreatitis. Gastroenterology 2010; 139:140-8; quiz e12-3. [PMID: 20353791 DOI: 10.1053/j.gastro.2010.03.054] [Citation(s) in RCA: 286] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 03/10/2010] [Accepted: 03/22/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Autoimmune pancreatitis (AIP) has been divided into subtypes 1 (lymphoplasmacytic sclerosing pancreatitis) and 2 (idiopathic duct centric pancreatitis). We compared clinical profiles and long-term outcomes of types 1 and 2 AIP. METHODS We compared clinical presentation, relapse, and vital status of 78 patients with type 1 AIP who met the original HISORt criteria and 19 patients with histologically confirmed type 2 AIP. RESULTS At presentation, patients with type 1 AIP were older than those with type 2 AIP (62 +/- 14 vs 48 +/- 19 years; P < .0001) and had a greater prevalence of increased serum levels of immunoglobulin G4 (47/59 [80%] vs 1/6 [17%]; P = .004). Patients with type 1 were more likely than those with type 2 to have proximal biliary, retroperitoneal, renal, or salivary disease (60% vs 0; P < .0001). Inflammatory bowel disease was associated with types 1 and 2 (6% vs 16%; P = .37). During median clinical follow-up periods of 42 and 29 months, respectively, 47% of patients with type 1 and none of those with type 2 experienced a relapse. In type 1 AIP, proximal biliary involvement (hazard ratio [HR], 2.12; P = .038) and diffuse pancreatic swelling (HR, 2.00; P = .049) were predictive of relapse, whereas pancreaticoduodenectomy reduced the relapse rate (vs the corticosteroid-treated group; HR, 0.15; P = .0001). After median follow-up periods of 58 and 89 months (types 1 and 2, respectively), the 5-year survival rates for both groups were similar to those of the age- and sex-matched US population. CONCLUSIONS Types 1 and 2 AIP have distinct clinical profiles. Patients with type 1 AIP have a high relapse rate, but patients with type 2 AIP do not experience relapse. AIP does not affect long-term survival.
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Affiliation(s)
- Raghuwansh P Sah
- Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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29
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Abstract
BACKGROUND Despite scattered case reports, the prevalence of inflammatory bowel disease (IBD) in patients with autoimmune pancreatitis (AIP) is unknown. We sought to better characterize the putative association between the conditions. METHODS Medical records of 71 patients meeting accepted criteria for AIP were reviewed to identify those with endoscopic and histological evidence of IBD. Colon samples in patients with both AIP and IBD were immunostained to identify IgG4-positive cells. RESULTS Four patients with AIP (5.6%) had a diagnosis of IBD: 3 had ulcerative colitis (UC) and 1 had Crohn's disease (CD). The diagnosis of IBD preceded or was simultaneous to that of AIP. Two AIP-UC patients treated for AIP with prednisone had a recurrence of AIP, and 1 required 6-mercaptopurine for long-term corticosteroid-sparing treatment. Two AIP-IBD patients underwent Whipple resections, and 1 had recurrent AIP. All 3 patients with UC presented with pancolitis, and 2 required colectomy. Colon samples from 1 patient with UC and 1 patient with CD were available for review. Increased numbers of IgG4-positive cells (10 per high-power field) were noted on the colon sample from the patient with UC. CONCLUSIONS Almost 6% of patients with proven AIP had a diagnosis of IBD, compared to a prevalence of approximately 0.4%-0.5% in the general population, potentially implying a 12-15-fold increase in risk. Patients with both AIP and IBD may have increased extent and severity of IBD. The finding of IgG4-positive cells on colon biopsy suggests that IBD may represent an extrapancreatic manifestation of AIP.
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Affiliation(s)
- Karthik Ravi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Singh VP, Bren GD, Algeciras-Schimnich A, Schnepple D, Navina S, Rizza SA, Dawra RK, Saluja AK, Chari ST, Vege SS, Badley AD. Nelfinavir/ritonavir reduces acinar injury but not inflammation during mouse caerulein pancreatitis. Am J Physiol Gastrointest Liver Physiol 2009; 296:G1040-6. [PMID: 19282375 PMCID: PMC2696210 DOI: 10.1152/ajpgi.90642.2008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 03/04/2009] [Indexed: 01/31/2023]
Abstract
There is no clinical treatment that reduces acinar injury during pancreatitis. Human immunodeficiency virus (HIV) protease inhibitors (PI), including nelfinavir (NFV) and ritonavir (RTV), may reduce the rate of pancreatitis in HIV-infected patients. Since permeability transition pore (PTPC)-mediated mitochondrial dysfunction occurs during pancreatitis, and we have shown that PI prevents PTPC opening, we studied its effects in a model of pancreatitis. The effect of NFV plus RTV (NFV/RTV) or vehicle on caerulein-induced pancreatitis in mice was compared by measuring changes in mitochondrial membrane potential in vitro and cytochrome c leakage in vivo. Histological and inflammatory makers were also compared. NFV/RTV improved DiOC6 retention in acini exposed to caerulein in vitro. In vivo NFV prevented cytosolic leakage of cytochrome c and reduced pancreatic acinar injury, active caspase-3 staining, TUNEL-positive acinar cells, and serum amylase (P < 0.05). Conversely, trypsin activity, serum cytokine levels, and pancreatic and lung inflammation were unaffected. NFV/RTV reduces pancreatic injury and acinar cell death in experimental mouse caerulein-induced pancreatitis but does not impact inflammation.
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Affiliation(s)
- Vijay P Singh
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Levy MJ, Topazian MD, Wiersema MJ, Clain JE, Rajan E, Wang KK, de la Mora JG, Gleeson FC, Pearson RK, Pelaez MC, Petersen BT, Vege SS, Chari ST. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol 2008; 103:98-103. [PMID: 17970834 DOI: 10.1111/j.1572-0241.2007.01607.x] [Citation(s) in RCA: 183] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Celiac plexus neurolysis and block are considered safe but provide limited pain relief. Standard techniques target the region of the celiac plexus but do not attempt injections directly into celiac ganglia. The recent recognition that celiac ganglia can be visualized by endoscopic ultrasound (EUS) now allows direct injection into celiac ganglia for neurolysis (CGN) and block (CGB). AIMS To determine the safety and initial efficacy (at 2-4 wk) of direct ganglia injection in patients with moderate to severe pain secondary to unresectable pancreatic carcinoma or chronic pancreatitis. METHODS An EUS database was reviewed to identify patients undergoing CGN and CGB. Data were retrieved from the medical records and phone follow-up. RESULTS Thirty-three patients underwent 36 direct celiac ganglia injections for unresectable pancreatic cancer (CGN N = 17, CGB N = 1) or chronic pancreatitis (CGN N = 5, CGB N = 13) with bupivacaine (0.25%) and alcohol (99%) for CGN, or Depo-Medrol (80 mg/2 cc) for CGB. Cancer patients reported pain relief in 16/17 (94%) when alcohol was injected and 0/1 (00%) when steroid was injected. For chronic pancreatitis, 4/5 (80%) who received alcohol reported pain relief versus 5/13 (38%) receiving steroids. Thirteen (34%) patients experienced initial pain exacerbation, which correlated with improved therapeutic response (P < 0.05). Transient hypotension and diarrhea developed in 12 and 6 patients, respectively. CONCLUSIONS Initial experience suggests that EUS-guided direct celiac ganglion block or neurolysis is safe. Alcohol injection into ganglia appears to be effective in both cancer and chronic pancreatitis. Prospective trials are needed to confirm the efficacy of this new approach.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Pelaez-Luna M, Chari ST, Smyrk TC, Takahashi N, Clain JE, Levy MJ, Pearson RK, Petersen BT, Topazian MD, Vege SS, Kendrick M, Farnell MB. Do consensus indications for resection in branch duct intraductal papillary mucinous neoplasm predict malignancy? A study of 147 patients. Am J Gastroenterol 2007; 102:1759-64. [PMID: 17686073 DOI: 10.1111/j.1572-0241.2007.01224.x] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent consensus guidelines suggest that presence of > or =1 of the following is an indication for resection (IR) of branch duct intraductal papillary mucinous neoplasm (IPMN-Br): cyst-related symptoms, main pancreatic duct diameter > or =10 mm, cyst size > or =30 mm, intramural nodules, or cyst fluid cytology suspicious/positive for malignancy. Among a cohort of patients with IPMN-Br we determined if the consensus IR (CIR), presence of multifocal IPMN-Br, or growth of cyst size on follow-up predict malignancy. METHODS We identified 147 patients with IPMN-Br of whom 66 underwent surgical resection at diagnosis and 81 were followed conservatively, of whom 11 were resected during follow-up. Clinical, imaging, histological, and cyst fluid characteristics from all 147 patients with IPMN-Br were obtained from clinical records and/or by contacting the patients. In all cases, presence of CIR at baseline and during follow-up (N = 66), presence of multifocal cysts (N = 57), and increase in cyst size (N = 38) were noted. RESULTS Among the 77 resected IPMN-Brs, at initial evaluation 61 had at least one CIR and 16 had none. Malignancy was present in 9/61 (15%) with CIR and 0/16 without IR (P= 0.1). When presence of any one of the CIR was taken as an indicator of malignancy, the CIR had a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 23%, 14%, and 100%, respectively. Prevalence of malignancy in those with single versus multifocal IPMN-Br was similar (13%vs 11%). No patient has developed malignancy after a median follow-up of 15 months. So far, none of the 38 patients with increase in cyst size on follow-up has developed malignancy related symptoms. CONCLUSIONS Suggested consensus indications for resection identify all patients with malignancy; however, their specificity is low. In the short term it would be safe to follow patients without these features.
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Affiliation(s)
- Mario Pelaez-Luna
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Abstract
BACKGROUND There is little information on dilation of proximal strictures following surgical and/or radiation therapy for head and neck cancer. We studied the feasibility and efficacy of dilating proximal strictures following therapy for head and neck cancer using Savary Gilliard dilators. METHODS Twenty-one consecutive patients with proximal strictures resulting from surgery and/or radiation therapy of head and neck cancer were studied. Savary Gilliard dilation was performed using the standard and a modified method. Dysphagia was graded before and after dilation using a 5-point scale. RESULTS Technical success, dysphagia relief, complications, and duration of relief were noted. Technical success was achieved in 20 (95%) patients. Adequate dysphagia relief was obtained in 15/20 (75%) patients, which lasted for 4-36 weeks (median 14 weeks). There were no perforations, bleeding, or deaths. Four patients required repeat dilation after a median interval of 12 weeks. CONCLUSIONS Savary Gilliard dilation is a safe and effective method for dilating strictures caused by therapy for head and neck cancer.
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Affiliation(s)
- V Dhir
- Division of Medical Gastroenterology, Tata Memorial Hospital, Parel, Bombay, India
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Dinshaw KA, Sharma V, Pendse AM, Telang CS, Vege SS, Malliat MK, Deshpande R, Desai PB. The role of intraluminal radiotherapy and concurrent 5-fluorouracil infusion in the management of carcinoma esophagus: a pilot study. J Surg Oncol 1991; 47:155-60. [PMID: 2072698 DOI: 10.1002/jso.2930470304] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Fifty patients with carcinoma of the esophagus were entered in a randomized pilot study to test the efficacy of intraluminal radiotherapy (ILRT) and concurrent 5-fluorouracil (5-FU) infusion. The median age was 65 years, with 80% having middle third lesions; in 62%, the lesions were longer than 5 cm. After external beam therapy of 50 Gy in 5 weeks, patients were randomized to receive chemotherapy. Significant improvement in dysphagia was recorded in 76% patients with complete response in 47 cases ranging from 6 to 27 months. The overall survival at 2 years was 15% with ILRT alone versus 22% with ILRT plus 5-FU infusion.
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Affiliation(s)
- K A Dinshaw
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Bombay, India
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