Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial.

BACKGROUND AND AIMS: Placement of a self-expandable metal stent (SEMS) across the duodenal major papilla carries a risk of duodenobiliary reflux (DBR). The suprapapillary method of stent placement may reduce DBR and improve stent patency compared with the transpapillary method. This study compared the clinical outcomes between the suprapapillary and transpapillary methods for distal malignant biliary obstruction (DMBO). METHODS: Between January 2021 and January 2023, consecutive patients with DMBO from 6 centers in South Korea were randomly assigned to either the suprapapillary arm or transpapillary method arm in a 1:1 ratio. The primary outcome was the duration of stent patency, and secondary outcomes were the cause of stent dysfunction, adverse events, and overall survival rate. RESULTS: Eighty-four patients were equally assigned to each group. The most common cause of DMBO was pancreatic cancer (50, 59.5%), followed by bile duct (20, 23.8%), gallbladder (11, 13.1%), and other cancers (3, 3.6%). Stent patency was significantly longer in the suprapapillary group (median, 369 days [interquartile range, 289-497] vs 154 days [interquartile range, 78-361]; P < .01). Development of DBR was significantly lower in the suprapapillary group (9.4% vs 40.8%, P < .01). Adverse events and overall survival rate were not significantly different between the 2 groups. CONCLUSIONS: The placement of SEMSs using the suprapapillary method resulted in a significantly longer duration of stent patency. It is advisable to place the SEMS using the suprapapillary method in DMBO. Further studies with a larger number of patients are required to validate the benefits of the suprapapillary method. (Clinical trial registration number: KCT0005572.).

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis.

OBJECTIVES: Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP. METHODS: We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI). RESULTS: In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2 = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2 = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686). CONCLUSIONS: Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Comparison of clinical/histological outcomes according to puncture sites in endoscopic ultrasound-guided fine needle biopsy for large pancreatic masses: Multicenter randomized prospective pilot study.

OBJECTIVES: There are no recommendations regarding the optimal puncture site in endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). This multicenter randomized prospective study compared the diagnostic accuracy and histological findings according to the sampling site for pancreatic masses larger than 3 cm. METHODS: Consecutive patients with pancreatic masses larger than 3 cm indicated for EUS-FNB were included in the study. Patients were randomly assigned to two groups for the initial puncture site (central vs. peripheral sampling of the masses). A minimum of four passes were performed, alternating between the center and the periphery. The primary outcome was diagnostic accuracy. RESULTS: A total of 100 patients were equally divided into the central group and the peripheral group. The final diagnosis revealed malignancy in 95 patients (pancreatic cancer [n = 89], neuroendocrine tumor [n = 4], lymphoma [n = 1], metastatic carcinoma [n = 1]), and benign conditions in five patients (chronic pancreatitis [n = 4], autoimmune pancreatitis [n = 1]). There was no significant difference in diagnostic accuracy between the puncture sites. However, combining samples from both areas resulted in higher diagnostic accuracy (97.0%) compared to either area alone, with corresponding values of 88.0% for the center (P = 0.02) and 85.0% for the periphery (P = 0.006). CONCLUSIONS: Both central sampling and peripheral sampling showed equivalent diagnostic accuracy in detecting malignancy. However, combining samples from both areas generated superior diagnostic yield compared to using either sampling site alone. For pancreatic masses larger than 3 cm, it is advisable to consider sampling from various areas of the masses to maximize the diagnostic yield.

Effectiveness and complication rates of percutaneous transhepatic fluoroscopy-guided management of common bile duct stones: a single-arm meta-analysis.

OBJECTIVES: To perform a systematic review and meta-analysis to determine the success and complication rate of percutaneous transhepatic fluoroscopy-guided management (PTFM) for the removal of common bile duct stones (CBDS). METHODS: A comprehensive literature search of multiple databases was conducted to identify original articles published between January 2010 and June 2022, reporting the success rate of PTFM for the removal of CBDS. A random-effect model was used to summarize the pooled rates of success and complications with 95% confidence intervals (CIs). RESULTS: Eighteen studies involving 2554 patients met the inclusion criteria and were included in the meta-analysis. Failed or infeasible endoscopic management was the most common indication of PTFM. The meta-analytic summary estimates of PTFM for the removal of CBDS were as follows: rate of overall stone clearance 97.1% (95% CI, 95.7-98.5%); stone clearance at first attempt 80.5% (95% CI, 72.3-88.6%); overall complications 13.8% (95% CI, 9.7-18.0%); major complications 2.8% (95% CI, 1.4-4.2%); and minor complications 9.3% (95% CI, 5.7-12.8%). Egger's tests showed the presence of publication bias with respect to the overall complications (p = 0.049). Transcholecystic management of CBDS had an 88.5% pooled rate for overall stone clearance (95% CI, 81.2-95.7%), with a 23.0% rate for complications (95% CI, 5.7-40.4%). CONCLUSION: The systematic review and meta-analysis answer the questions of the overall stone clearance, clearance at first attempt, and complication rate of PTFM by summarizing the available literature. Percutaneous management could be considered in cases with failed or infeasible endoscopic management of CBDS. CLINICAL RELEVANCE STATEMENT: This meta-analysis highlights the excellent stone clearance rate achieved through percutaneous transhepatic fluoroscopy-guided removal of common bile duct stones, potentially influencing clinical decision-making when endoscopic treatment is not feasible. KEY POINTS: • Percutaneous transhepatic fluoroscopy-guided management of common bile duct stones had a pooled rate of 97.1% for overall stone clearance and 80.5% for clearance at the first attempt. • Percutaneous transhepatic management of common bile duct stones had an overall complication rate of 13.8%, including a major complication rate of 2.8%. • Percutaneous transcholecystic management of common bile duct stones had an overall stone clearance rate of 88.5% and a complication rate of 23.0%.

Differentiation of autoimmune pancreatitis from pancreatic adenocarcinoma using CT characteristics: a systematic review and meta-analysis.

OBJECTIVES: To determine informational CT findings for distinguishing autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to review their diagnostic accuracy. METHODS: A systematic and detailed literature review was performed through PubMed, EMBASE, and the Cochrane library. Similar descriptors to embody the identical image finding were labeled as a single CT characteristic. We calculated the pooled diagnostic odds ratios (DORs) of each CT characteristic using a bivariate random-effects model. RESULTS: A total of 145 various descriptors from 15 studies (including 562 AIP and 869 PDAC patients) were categorized into 16 CT characteristics. According to the pooled DOR, 16 CT characteristics were classified into three groups (suggesting AIP, suggesting PDAC, and not informational). Seven characteristics suggesting AIP were diffuse pancreatic enlargement (DOR, 48), delayed homogeneous enhancement (DOR, 46), capsule-like rim (DOR, 34), multiple pancreatic masses (DOR, 16), renal involvement (DOR, 15), retroperitoneal fibrosis (DOR, 13), and bile duct involvement (DOR, 8). Delayed homogeneous enhancement showed a pooled sensitivity of 83% and specificity of 85%. The other six characteristics showed relatively low sensitivity (12-63%) but high specificity (93-99%). Four characteristics suggesting PDAC were discrete pancreatic mass (DOR, 23), pancreatic duct cutoff (DOR, 16), upstream main pancreatic duct dilatation (DOR, 8), and upstream parenchymal atrophy (DOR, 7). CONCLUSION: Eleven CT characteristics were informational to distinguish AIP from PDAC. Diffuse pancreatic enlargement, delayed homogeneous enhancement, and capsule-like rim suggested AIP with the highest DORs, whereas discrete pancreatic mass suggested PDAC. However, pooled sensitivities of informational CT characteristics were moderate. CLINICAL RELEVANCE STATEMENT: This meta-analysis underscores eleven distinctive CT characteristics that aid in differentiating autoimmune pancreatitis from pancreatic adenocarcinoma, potentially preventing misdiagnoses in patients presenting with focal/diffuse pancreatic enlargement. KEY POINTS: • Diffuse pancreatic enlargement (pooled diagnostic odds ratio [DOR], 48), delayed homogeneous enhancement (46), and capsule-like rim (34) were CT characteristics suggesting autoimmune pancreatitis. • The CT characteristics suggesting autoimmune pancreatitis, except delayed homogeneous enhancement, had a general tendency to show relatively low sensitivity (12-63%) but high specificity (93-99%). • Discrete pancreatic mass (pooled diagnostic odds ratio, 23) was the CT characteristic suggesting pancreatic ductal adenocarcinoma with the highest pooled DORs.

Comparison of the long-term outcomes between proximal and distal IgG4-related sclerosing cholangitis: A multicenter cohort study.

BACKGROUND AND AIMS: Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is considered a biliary manifestation of IgG4-related diseases. However, there has been a controversy on the clinical outcomes according to the location of the involved bile duct. We therefore compared the clinical outcomes and long-term prognosis of IgG4-SC with proximal bile duct involvement (proximal IgG4-SC) and IgG4-SC with distal bile duct involvement (distal IgG4-SC). METHODS: We reviewed the data of patients with IgG4-SC that were prospectively collected at 10 tertiary centers between March 2002 and October 2020. Clinical manifestations, outcomes, association with autoimmune pancreatitis (AIP), steroid-responsiveness, and relapse of IgG4-SC were evaluated. RESULTS: A total of 148 patients (proximal IgG4-SC, n = 59; distal IgG4-SC, n = 89) were analyzed. The median age was 65 years (IQR, 56.25-71), and 86% were male. The two groups were similar in terms of jaundice at initial presentation (51% vs 65%; P = 0.082) and presence of elevated serum IgG4 (66% vs 70%; P = 0.649). The two groups showed significant differences in terms of steroid-responsiveness (91% vs 100%; P = 0.008), association with AIP (75% vs 99%; P = 0.001), and occurrence of liver cirrhosis (9% vs 1%; P = 0.034). During a median follow-up of 64 months (IQR, 21.9-84.7), the cumulative relapse-free survival was significantly different between the two groups (67% vs 79% at 5 years; P = 0.035). CONCLUSIONS: Relapse of IgG4-SC frequently occurred during follow-up. Proximal IgG4-SC and distal IgG4-SC had different long-term outcomes in terms of steroid-responsiveness, occurrence of liver cirrhosis, and recurrence. It may be advantageous to determine the therapeutic and follow-up strategies according to the location of bile duct involvement.

Long-term outcomes of endoscopic papillectomy for ampullary adenoma with high-grade dysplasia or adenocarcinoma: a propensity score-matched analysis.

BACKGROUND: Evidence of endoscopic papillectomy (EP) for ampullar adenoma with high-grade dysplasia (HGD) or adenocarcinoma is insufficient. Here we investigated the long-term outcomes of the advanced ampullary tumors treated by EP with careful surveillance comparing to subsequent surgery after EP. METHODS: Patients treated with EP for ampullary adenoma with HGD or adenocarcinoma from the multi-center retrospective Korean cohort of ampulla of Vater tumor were categorized into EP alone versus EP with subsequent surgery groups. The overall survival (OS) and recurrence-free survival (RFS) were analyzed for unmatched and matched cohorts using propensity score with nearest neighbor method. RESULTS: During a median 43.3 months of follow-up, 5-year OS was not significantly different between the EP alone and EP surgery groups (91.9% vs. 82.3%, P = 0.443 for unmatched cohort; 89.2% vs. 82.3%, P = 0.861 for matched cohort, respectively). Furthermore, 5-year RFS was not significantly different between the two groups (82.1% vs. 86.7%, P = 0.520 for unmatched cohort; 66.1% vs. 86.7%, P = 0.052 for matched cohort, respectively). However, the patients with positive both (lateral and deep) margins showed significantly poorer survival outcomes than those with negative margins within the EP alone group (P = 0.007). CONCLUSION: EP alone with careful surveillance showed comparable survival outcomes to those of EP with subsequent surgery for ampullar HGD or adenocarcinoma. Resection margin status could be a parameter to determine whether to perform subsequent radical surgery after EP.

Systematic review and meta-analysis of percutaneous transluminal forceps biopsy for diagnosing malignant biliary strictures.

OBJECTIVES: To perform a systematic review and meta-analysis to determine the diagnostic performance of percutaneous transluminal forceps biopsy (PTFB) for differentiating malignant from benign biliary stricture. METHODS: A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted to identify original articles published between January 2001 and January 2021 reporting the diagnostic accuracy of PTFB. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS: Fourteen studies involving 1762 patients met the inclusion criteria and were included in the meta-analysis. The meta-analysis summary estimates of PTFB for diagnosis of malignant biliary strictures were as follows: sensitivity 81% (95% confidence interval [CI], 78-81%); specificity 100% (95% CI, 98-100%); diagnostic odds ratio 85.34 (95% CI, 38.37-189.81). The area under the curve of PTFB was 0.948 in the diagnosis of malignant biliary strictures. The diagnostic sensitivity was higher in intrinsic (85%) than in extrinsic (73%) biliary strictures. The pooled rate of all complications was 10.3% (95% CI, 7.0-14.2%), including a major complication rate of 3.1%. CONCLUSION: These data demonstrate that PTFB is sensitive and highly specific for diagnosing malignancy in biliary strictures. PTFB should be incorporated into future guidelines for tissue sampling in biliary cancer, especially in cases with failed endoscopic management. KEY POINTS: • PTFB had a good overall diagnostic performance for differentiating malignant from benign biliary strictures, with a meta-analysis summary estimate of 81% for sensitivity and 100% for specificity. • PTFB had higher sensitivity for cholangiocarcinoma (85%) than for other cancers (73%). • PTFB had a 100% technical success rate and a 10.3% rate for complications, including a 3.1% rate for major complications.

Systematic review and meta-analysis of MRI features for differentiating autoimmune pancreatitis from pancreatic adenocarcinoma.

OBJECTIVES: To identify reliable MRI features for differentiating autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to summarize their diagnostic accuracy. METHODS: We conducted a systematic literature review and meta-analysis using PubMed, EMBASE, and the Cochrane Library to identify original articles published between January 2006 and July 2021. The pooled diagnostic accuracy, including the diagnostic odds ratios (DORs) with 95% confidence intervals (CIs) of the identified features, was calculated using a bivariate random effects model. RESULTS: Twelve studies were included, and 92 overlapping descriptors were subsumed under 16 MRI features. Ten features favoring AIP were diffuse enlargement (DOR, 75; 95% CI, 9-594), capsule-like rim (DOR, 52; 95% CI, 20-131), multiple main pancreatic duct (MPD) strictures (DOR, 47; 95% CI, 17-129), homogeneous delayed enhancement (DOR, 46; 95% CI, 21-104), low apparent diffusion coefficient value (DOR, 30), speckled enhancement (DOR, 30), multiple pancreatic masses (DOR, 29), tapered narrowing of MPD (DOR, 15), penetrating duct sign (DOR, 14), and delayed enhancement (DOR, 13). Six features favoring PDAC were target type enhancement (DOR, 41; 95% CI, 11-158), discrete pancreatic mass (DOR, 35; 95% CI, 15-80), upstream MPD dilatation (DOR, 13), peripancreatic fat infiltration (DOR, 10), upstream parenchymal atrophy (DOR, 5), and vascular involvement (DOR, 3). CONCLUSION: This study identified 16 informative MRI features to differentiate AIP from PDAC. Among them, diffuse enlargement, capsule-like rim, multiple MPD strictures, and homogeneous delayed enhancement favored AIP with the highest DORs, whereas discrete mass and target type enhancement favored PDAC. KEY POINTS: • The MRI features with the highest pooled diagnostic odds ratios (DORs) for autoimmune pancreatitis were diffuse enlargement of the pancreas (75), capsule-like rim (52), multiple strictures of the main pancreatic duct (47), and homogeneous delayed enhancement (46). • The MRI features with the highest pooled DORs for pancreatic ductal adenocarcinoma were target type enhancement (41) and discrete pancreatic mass (35).

Brush Cytology, Forceps Biopsy, or Endoscopic Ultrasound-Guided Sampling for Diagnosis of Bile Duct Cancer: A Meta-Analysis.

Endoscopic sampling is essential for tissue diagnosis of cholangiocarcinoma (CCA). To evaluate and compare the diagnostic sensitivities of endoscopic retrograde cholangiopancreatography-guided brush cytology biopsy, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with CCA. A comprehensive literature search through multiple databases was conducted for articles published between January 1995 and August 2020. The pooled rates of sensitivity for the diagnosis of CCA and of adverse events were compared among brushing, biopsy, brushing & biopsy, and EUS-FNA. In total, 1123 patients with CCA (32 studies), 719 patients (20 studies), 358 patients (13 studies), and 422 patients (17 studies) were tested by brushing, biopsy, brushing & biopsy, and EUS-FNA, respectively. The pooled diagnostic sensitivity was 56.0% (95% confidence interval (CI) 48.8-63.1%, I2 = 83.0%) with brushing, 67.0% (95% CI 60.2-73.5%, I2 = 72.5%) with biopsy, 70.7% (95% CI 64.1-76.8%, I2 = 42.7%) with brushing & biopsy, and 73.6% (95% CI 64.7-81.5%, I2 = 74.7%) with EUS-FNA. The diagnostic sensitivity was significantly lower for brushing than for biopsy, brushing & biopsy, or EUS-FNA. No significant difference was noted in diagnostic sensitivities among biopsy, brushing & biopsy, and EUS-FNA. Adverse events were comparable between the groups. Intraductal biopsy, brushing & biopsy, and EUS-FNA had comparable efficacy and safety for the diagnosis of CCA. Brushing was the least sensitive diagnostic tool compared with intraductal biopsy or EUS-FNA. Given the modest diagnostic sensitivities of intraductal biopsy and EUS-FNA in the diagnosis of CCA, further studies for complementing these techniques with biomarkers may be needed.

Determination of the duration of glucocorticoid therapy in type 1 autoimmune pancreatitis: A systematic review and meta-analysis.

BACKGROUND: The indications for maintenance glucocorticoid therapy (MGT) and its duration after initial remission of type 1 autoimmune pancreatitis (AIP) remain controversial. In contrast to the Japanese treatment protocol, the Mayo protocol does not recommend MGT after initial remission. This study aimed to evaluate the relapse rate in patients with type 1 AIP according to the duration of glucocorticoid therapy. METHODS: We conducted a systematic literature review up until November 30, 2020, and identified 40 studies reporting AIP relapse rates. The pooled relapse rates were compared between groups according to the protocol and duration of glucocorticoids (routine vs. no MGT; glucocorticoids ≤6 months vs. 6-12 months vs. 12-36 months vs. ≥ 36 months). The pooled rates of adverse events related to glucocorticoids were also evaluated. RESULTS: Meta-analysis indicated calculated pooled relapse rates of 46.6% (95% confidence interval (CI), 38.9-54.3%) with glucocorticoids for ≤ 6 months, 44.3% (95% CI, 38.8-49.8%) for 6-12 months, 34.1% (95% CI, 28.6-39.7%) for 12-36 months, and 27.0% (95% CI, 23.4-30.6%) for ≥ 36 months. The rate of relapse was also significantly lower in patients with routine-use protocol of MGT (31.2%; 95% CI, 27.5-34.8%) than in patients with no MGT protocol (44.1%; 95% CI, 35.8-52.4%). Adverse events were comparable between groups. CONCLUSIONS: The rate of relapse tended to decrease with extended durations of glucocorticoid therapy up to 36 months. Clinicians may decide the duration of glucocorticoids according to patient condition, including comorbidities and risk of relapse.

Endoscopic ultrasound-guided fine needle aspiration versus biopsy for diagnosis of autoimmune pancreatitis: Systematic review and comparative meta-analysis.

BACKGROUND: Endoscopic ultrasound (EUS) is recommended for guiding the acquisition of pancreatic tissue in patients with suspected autoimmune pancreatitis (AIP). Data comparing EUS-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) sampling in the diagnosis of AIP are limited. METHODS: A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted until April 2020. The pooled rates of diagnostic yield for the histologic criteria of AIP, histologic tissue procurement, and adverse events were compared between FNA and FNB. Diagnostic yields were also compared between 19 gauge (G) and 22G needles. RESULTS: This meta-analysis included nine studies comprising 309 patients with AIP who underwent FNA and seven studies comprising 131 patients who underwent FNB. The pooled diagnostic yields for level 1 or 2 histology criteria of AIP were 55.8% (95% confidence interval (CI) 37.0-73.9%, I2  = 91.1) for FNA and 87.2% (95% CI 68.8-98.1%, I2  = 69.4) for FNB (P = 0.030). The pooled histologic procurement rates for FNA and FNB were 91.3% (95% CI, 84.9-97.6%, I2  = 82.9) and 87.0% (95% CI, 77.8-96.1%, I2  = 40.0), respectively (P = 0.501). Adverse events were comparable between two groups. When analyzed by needle size, the diagnostic yield was better with a 19G needle than with a 22G needle (88.9% vs. 60.6%, P = 0.023). CONCLUSIONS: The diagnostic yield may be better with FNB needles than with FNA needles for the diagnosis of AIP, despite the similar rate of histologic tissue procurement. A quantitative definition for the histologic sample adequacy for AIP may be warranted.

The use of immunohistochemistry for IgG4 in the diagnosis of autoimmune pancreatitis: A systematic review and meta-analysis.

BACKGROUND: The diagnosis of autoimmune pancreatitis (AIP) remains challenging, especially when serum IgG4 is normal or imaging features are indeterminate. We performed a systematic review and meta-analysis to evaluate the performance of IgG4 immunostaining of pancreatic, biliary, and ampullary tissues as a diagnostic aid for AIP. METHODS: A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted until February 2020. The methodological quality of each study was assessed according to the Quality Assessment of Diagnostic Accuracy Studies checklist. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy. RESULTS: The meta-analysis included 20 studies comprising 346 patients with AIP and 590 patients with other pancreatobiliary diseases, including 371 pancreatobiliary malignancies. The summary estimates for tissue IgG4 in discriminating AIP and controls were as follows: diagnostic odds ratio 38.86 (95% confidence interval (CI), 18.70-80.75); sensitivity 0.64 (95% CI, 0.59-0.69); specificity 0.93 (95% CI, 0.91-0.95). The area under the curve was 0.939 for tissue IgG4 in discriminating AIP and controls. Subgroup analysis revealed no significant difference in diagnostic accuracy according to control groups (pancreatobiliary cancer versus other chronic pancreatitis) and sampling site (pancreas versus bile duct/ampulla). CONCLUSIONS: Current data demonstrate that IgG4 immunostaining of pancreatic, biliary, and ampullary tissue has a high specificity but moderate sensitivity for diagnosing AIP. IgG4 immunostaining may be useful in supporting a diagnosis of AIP when AIP is clinically suspected, but a combination of imaging and serology does not provide a conclusive diagnosis.

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

BACKGROUND: Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. METHODS: Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6 days (range 1-30 days), and median duration of hospitalization was 13 days (range 3-135 days). At the follow-up (mean 24.6 months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. CONCLUSIONS: Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

Impact of body fat and muscle distribution on severity of acute pancreatitis.

BACKGROUND/OBJECTIVES: Obesity is a well-established risk factor for severe acute pancreatitis (AP); however, the impact of visceral obesity or sarcopenic obesity on severity of AP has not been well studied. We compared the relationship between severity of AP and various body parameters including body weight, body mass index (BMI), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and visceral fat-to-muscle ratio (VMR). METHODS: We analyzed the data of patients who were diagnosed with AP from 2009 to 2015. Image analysis software program (Aquarius Workstation software) was used to calculate individual VAT, SAT, and skeletal muscle areas from abdominal computed tomography scans at L3 vertebral levels. Revised Atlanta Classification was adopted to define severity of AP. Receiver operating characteristics (ROC) curves were constructed to determine the optimal threshold for predicting the severity. RESULTS: Among 203 patients, 13 (6.4%) patients had severe AP and 62 (30.5%) patients had moderately severe cases. VMR demonstrated the highest area under the ROC curve [0.757, (95% confidence interval: 0.689-0.825)] in predicting moderately severe or severe AP. The optimal threshold of VMR for predicting severity was 1. The prevalence of various local complications and persistent organ failure were higher in patients with VMR over 1. CONCLUSIONS: High visceral fat with low skeletal muscle volume was strongly correlated with AP severity. VMR had a stronger correlation with AP severity than body weight or BMI. This simple grading system would be useful if incorporated into future predictive scoring models.

Esophagogastric junction contractile integral and morphology: Two high-resolution manometry metrics of the anti-reflux barrier.

BACKGROUND AND AIM: We evaluated associations of esophagogastric junction (EGJ) metrics as an anti-reflux barrier with impedance-pH, endoscopic esophagitis, and lower esophageal sphincter (LES) metrics. METHODS: We reviewed high-resolution manometry data from consecutive patients with gastroesophageal reflux disease (GERD) symptoms who underwent impedance-pH and endoscopy, and asymptomatic volunteers. The EGJ contractile integral (CI) was calculated as the mean contractile integral/second during three respiratory cycles. EGJ morphology was classified according to LES-crural diaphragm (CD) separation. RESULTS: In total, 137 patients (65 male, age 55 years) and 23 (9 male, age 33 years) controls were enrolled. Twenty-five patients had erosive reflux disease (ERD), 16 had non-erosive reflux disease (NERD), 5 had reflux hypersensitivity, and 91 were not GERD. EGJ-CI were lower in patients with GERD (22.6 [13.8-29.2] mmHg cm) than non-GERD (50.3 [31-69.9] mmHg cm, P < 0.01) and controls (67 [26.7-78.7] mmHg cm). With an EGJ-CI cut-off value of 30 mmHg cm, the area under the curve was 0.814 (0.762-0.896), with 77.8% sensitivity and 81.7% specificity for the prediction of GERD. LES-CD separation was greatest in patients with ERD, followed the NERD, non-GERD, and controls. EGJ morphology type III was associated with a higher DeMeester score (7.9 [1.6-12.6]) than were type II (3.25 [0.9-5.975]) and I (1.75 [0.8-6.2]; P < 0.01). EGJ-CI values were lower in patients with GERD than in others in each EGJ morphology subgroup. CONCLUSION: Esophagogastric junction contractile integral showed good diagnostic accuracy with high specificity in predicting GERD. LES-CD separation is associated with an increase in acid reflux, but EGJ-CI was associated more strongly with GERD than was EGJ morphology.

Body Mass Index and Clinical Outcomes from Endoscopic Submucosal Dissection of Gastric Neoplasia.

BACKGROUND AND AIM: Association between obesity and endoscopic resection outcomes has not been investigated. We sought to determine the clinical impact of obesity in patients who underwent endoscopic submucosal dissection (ESD) for gastric neoplasia. METHODS: A total of 1571 consecutive patients with gastric neoplasia who underwent ESD between December 2010 and March 2016 were enrolled in this study. We retrospectively analyzed 1181 cases that were divided into three groups based upon body mass index (BMI, kg/m2) according to the criteria for Asia-Pacific populations: normal (<23, n = 411), overweight (≥23 and <25, n = 312), and obese (≥25, n = 458). Demographics, endoscopic findings, pathologic results, and clinical outcomes were analyzed. RESULTS: No significant differences were observed between the three BMI groups in the following measures: the en-bloc resection rate, the complete resection rate, lymphovascular involvement or submucosal invasion of tumor cells, and adverse events. However, when comparing the obese and overweight groups with the normal group, mean procedure time was longer (P = 0.001) and the percentage of cases requiring more than 30 min, which was the overall mean procedure time, was greater (60.7, 53.2, and 50.1%, respectively; P = 0.006). The significantly associated factors with procedure durations longer than 30 min were obesity, longitudinal and circumferential location, large resection size (≥4 cm), cancer pathology, and submucosal layer invasion. In multivariate analyses, obesity was an independent predictor of long procedure time for gastric ESD. CONCLUSION: Being obese or overweight did not directly affect clinical outcomes in gastric ESD. However, obesity was significantly associated with long procedure time. Our results suggest that gastric ESD can be performed safely and effectively in obese patients.

Bleeding After Endoscopic Procedures in Patients With Chronic Hematologic Thrombocytopenia.

BACKGROUND: Procedure-induced bleeding is a major complication after endoscopic intervention. AIMS: The aim of this study was to investigate the risk of endoscopy-related bleeding in patients with chronic hematologic thrombocytopenia. METHODS: We investigated endoscopy-related bleeding in 175 procedures performed on 108 patients with immune thrombocytopenic purpura or aplastic anemia. The outcomes were compared with those of 350 procedures on age-, sex-, and procedure-matched control subjects. Endoscopic interventions included low-risk procedures such as endoscopic biopsy and high-risk procedures including polypectomy, endoscopic resection, and endoscopic retrograde cholangiopancreatogram with sphincterotomy. RESULTS: Bleeding occurred in 17 (9.7%) procedures among the patients with thrombocytopenia. This rate was significantly higher than that in procedures on controls (3.1%, P = 0.003). About 60% of all bleeding events were observed within 24 h after the endoscopic procedure. Bleeding after endoscopic biopsy developed more frequently in the patient group than in the control group (7.1 vs. 0.7%; P < 0.001). Bleeding occurred after 20% of all high-risk procedures. The incidence of bleeding was significantly elevated in patients with a platelet count less than 50 × 103/µl. Multivariate analysis revealed that high-risk procedures and low platelet count (less than 50 × 103/µl) were significantly related to procedure-related bleeding. All bleeding events stopped spontaneously or were controlled with endoscopic hemostasis. CONCLUSIONS: Endoscopic procedure-related bleeding develops frequently in patients with chronic hematologic thrombocytopenia. Post-procedural bleeding should be observed carefully in these patients, especially when the platelet count is less than 50 × 103/µl or high-risk endoscopic procedures are planned.

Incidence of gastric cancer after endoscopic resection of gastric adenoma.

BACKGROUND AND AIMS: The annual incidence of metachronous cancer after endoscopic resection (ER) of early gastric cancer (EGC) is approximately 3%. However, the incidence of gastric cancer after ER of a gastric adenoma is not known. The aim of this study was to determine whether the incidence of gastric cancer after ER of a gastric adenoma was different compared with that of metachronous cancer after ER of EGC. METHODS: We retrospectively analyzed data from patients who underwent ER for gastric neoplasia from January 2005 to August 2013. Enrolled patients were divided into 2 groups: patients with low-grade dysplasia were included in the adenoma group and patients with high-grade dysplasia or invasive neoplasia were included in the EGC group. The main outcome was the incidence of gastric cancer after ER. RESULTS: At a median follow-up of 28 months, gastric cancer newly developed in 13 adenoma patients (3.6%) and in 30 EGC patients (5.1%). The incidence rate of gastric cancer after ER was 14.4 cases per 1000 person-years in adenoma patients and 18.4 cases per 1000 person-years in EGC patients (P = .309 by the log-rank test). The hazard ratio of metachronous neoplasia in adenoma patients compared with EGC patients was 0.97 (95% confidence interval, 0.62-1.53). Metachronous tumors with invasion beyond the muscularis mucosa were more frequent in adenoma patients than in EGC patients (7/35 [20.0%] vs 3/63 [4.8%], P = .017). CONCLUSION: The incidence of gastric cancer after ER for gastric adenoma was not significantly different from that of EGC. If further prospective studies confirm these findings, careful endoscopic surveillance with the same level of intensity should be considered for both gastric adenoma and EGC patients after ER.

Role of follow-up endoscopic examination in treatment response assessment for patients with gastric diffuse large B cell lymphoma.

OBJECTIVE: According to lymphoma guidelines, gastric diffuse large B cell lymphoma (DLBCL) patients should undergo regular computed tomography (CT) and/or positron emission tomography (PET) examinations to assess treatment response. Endoscopic examinations are not indicated in the guidelines. The aim of this study was to investigate the utility of endoscopic examinations during and after treatment for DLBCL. METHODS: We reviewed the patients diagnosed with gastric DLBCL at Seoul St. Mary's Hospital. All patients underwent endoscopy and radiologic examinations at every follow-up appointment. Radiologic response was defined according to World Health Organization criteria and endoscopic response was determined based on the Groupe d'Etude des Lymphomes de l'Adult grading system that is widely used in post-treatment evaluation of gastric MALT lymphoma. RESULTS: Forty-five patients were analyzed. Within a median follow-up period of 34 months, 35 patients achieved both radiologic and endoscopic complete remission (CR). The median times to endoscopic and radiologic CR were not significantly different (21 versus 16 weeks, p = 0.118). However, in 25 patients with stage I disease, endoscopic CR [median (range), 20 (11-36)] was achieved later than radiologic CR [median (range), 13 (8-36)] (p = 0.027). Among 40 patients who achieved radiologic CR, 35 patients who also achieved endoscopic CR maintained remission during the follow-up. Two of the five patients who achieved radiologic CR without endoscopic CR experienced recurrence. CONCLUSIONS: In gastric DLBCL patients, endoscopic response does not always correlate with radiologic response and might predict disease recurrence. We suggest that follow-up endoscopic examination with biopsy should be performed in addition to radiologic examination.