Integrating Molecular Analysis into the Pathologic Evaluation of Pancreatic Cysts.

The development of cross-sectional imaging techniques has enhanced the detection of pancreatic cystic lesions (PCLs). PCLs are found in approximately 2% of the general population, often as incidentally detected lesions on computed tomography or MRI during the evaluation of other medical conditions. Broadly, PCLs are classified as mucinous or nonmucinous. Mucinous PCLs include mucinous cystic neoplasms and intraductal papillary mucinous neoplasms. Nonmucinous PCLs include pseudocysts, serous cystadenomas, solid pseudopapillary neoplasms, and cystic pancreatic neuroendocrine tumors, as well as cystic acinar cell carcinoma, cystic degeneration of pancreatic ductal adenocarcinoma, lymphoepithelial cyst, and others.

Diagnostic accuracy of EUS-guided through-the-needle-biopsies and simultaneously obtained fine needle aspiration for cytology from pancreatic cysts: A systematic review and meta-analysis.

OBJECTIVES: To address the diagnostic accuracy of endoscopic ultrasound guided through-the-needle-biopsies (TTNBs) and simultaneously obtained cytology samples from pancreatic cysts compared to the final histopathological diagnosis of the surgical specimen, and to give an overview of ancillary tests performed on TTNBs. METHODS: A literature search was conducted in MEDLINE, Embase and Scopus. Studies were included in the meta-analysis, if they had data for TTNB, cytology and a surgical specimen of pancreatic cysts as reference standard. The assessment of the risk of bias and quality of the included studies was conducted using the modified QUADAS-2 tool. RESULTS: Ten studies with 99 patients were included in the meta-analysis. Data regarding study design and clinicopathological features were extracted systematically. For TTNB, pooled sensitivity was 0.86 (95 % CI 0.62-0.96), specificity 0.95 (95 % CI 0.79-0.99) and area under the curve (AUC) 0.86 for the diagnosis of a mucinous cyst and pooled sensitivity was 0.78 (95 % CI 0.61-0.89), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.92 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.69 (95 % CI 0.50-0.83), specificity 0.47 (95 % CI 0.28-0.68) and AUC 0.49. For cytology performed simultaneously, pooled sensitivity was 0.46 (95 % CI 0.35-0.57), specificity 0.90 (95 % CI 0.46-0.99) and AUC 0.64 for the diagnosis of mucinous cysts, and pooled sensitivity was 0.38 (95 % CI 0.23-0.55), specificity 0.99 (95 % CI 0.90-0.99) and AUC 0.84 for the diagnosis of a high-risk cyst. For a specific diagnosis, pooled sensitivity was 0.29 (95 % CI 0.21-0.39), specificity 0.45 (95 % CI 0.25-0.66) and AUC 0.30. Furthermore, immunohistochemical stains can be useful to establish the specific cyst subtype. CONCLUSIONS: TTNBs have a higher sensitivity and specificity than cytology for the diagnosis of mucinous cyst and high- risk cysts of the pancreas.

Short-term outcome of local pancreatic complications in a public hospital from North India.

INTRODUCTION: Dearth in the literature pertaining to natural history of acute pancreatitis (AP) necessitates further studies to evaluate the outcome of local pancreatic complications using the revised Atlanta classification. OBJECTIVE: To evaluate the outcomes of local pancreatic complications after first episode of AP, risk factors for their development and predictors of need for intervention. METHODOLOGY: A prospective study was carried out on 50 consecutive cases of AP who developed local pancreatic complications from January 2015 to July 2016. After imaging, they were categorised into acute pancreatic fluid collection (APFC) and acute necrotic collection (ANC). The risk factors for their development and the need for intervention were assessed. RESULTS: Of 50 patients, 20 developed APFC and 30 ANC. Of ANC cases, 27 progressed into walled-off necrosis (WON), of which 4 were managed conservatively and 18 collections were drained percutaneously, 3 underwent endotherapy (transmural drainage and endoscopic necrosectomy) and 2 died following percutaneous drainage (PCD) and surgery. Ten WON collections persisted at the end of 3rd month. Collections resolved in 6 of 20 APFC patients, 14 formed pseudocysts, of which 10 showed resolution with or without intervention and only 4 of them persisted at the end of study. Size of collection ≥6 cm was independent predictor of intervention irrespective of type of collections while in cases of ANC, extensive necrosis (>30%) and multiple collections were more likely to require intervention. CONCLUSION: Incidence of ANC is more common than APFC when local pancreatic fluid collections develop most of which develop WON and require intervention.

Hemorrhagic pancreatic pseudocyst: A rare complication.

Pancreatic pseudocysts are seen both in acute and chronic pancreatitis. Prevalence of pancreatic pseudocyst in chronic pancreatitis is 20% to 40% and is most commonly seen in alcoholic chronic pancreatitis. Intracystic hemorrhage from a pseudoaneurysm is a rare and potentially a lethal complication of pancreatic pseudocyst with an incidence of less than 10%. We herein present a case of a 42-year-old male with a past medical history of chronic alcoholic pancreatitis, stable pseudocyst in the tail of pancreas, alcohol abuse and seizures who presented with abdominal pain and acute anemia had this rare complication of hemorrhagic pseudocyst. The diagnostic modalities used to diagnose hemorrhagic pseudocyst are ultrasound with color doppler, CT with contrast, digital subtraction angiography and angiography. Angiographic embolization of the culprit artery is the preferred treatment of choice in the treatment of pseudoaneurysms. It is important for early recognition and treatment of this complication as the mortality can be as high as 40%.

Endoscopy-assisted, single trans-gastric trocar, laparoscopic pseudocysto-gastrostomy A minimally invasive alternative for drainage of large pseudocysts.

INTRODUCTION: Pancreatic pseudocyst is a complication of acute and chronic pancreatitis, which requires treatment in correlation with its size, symptomatology and mass effect on adjacent structures. Currently, pseudocyst drainage can be done within the stomach or small intestine through endoscopic, laparoscopic or open surgery approach. AIMS: In this paper we present a hybrid surgical technique applied by our team on 3 consecutive patients with pancreatic pseudocyst. METHOD: The pseudocysts were in all cases internally drained by endoscopic assisted laparoscopic approach, this article highlighting the technical aspects of this procedures. The patients were known with repeated episodes of acute pancreatitis. Imaging examinations indicated the presence of large pancreatic pseudocysts in all cases, for which we decided to perform a mechanical pseudo-cysto-gastro-anastomosis done laparoscopically-trans-gastric through a single trocar under endoscopic guidance. RESULTS: The length of surgery was from 60 to 90 min with no intraoperative blood loss recorded. The laparoscopic ultrasound was used in all cases to facilitate the safe localization of the future anastomotic site. The laparoscopic examination of the pseudocyst cavity was done systematically and in 2 cases revealed necrotic areas requiring debridement. The patients had no postoperative complications and were discharged 4-6 days after surgery. CONCLUSIONS: Internal drainage of pancreatic pseudocyst inside the stomach, by the technique described above, is facile, giving the patient the advantages of endoscopy and minimally invasive surgery. In these circumstances, we consider it superior to endoscopic drainage, by providing a broad communication between the pseudocyst and stomach cavity, reducing the risk of relapse and abscess formation. Moreover, it offers the possibility of exploring the pseudocyst cavity and of removing any necrotic tissues. The endoscopic assistance makes possible the single trans-gastric trocar approach, limiting the injury of the gastric wall. KEY WORDS: Endoscopic assisted laparoscopic procedure, Hybrid technique, Pancreatic pseudocyst, Pseudo-cystogastro- anastomosis technique.

Successful use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) on a pancreatic lesion in a peritoneal dialysis patient without interrupting treatment.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), a well-established minimally invasive gastrointestinal procedure, has been used to diagnose and stage cancers of the pancreas. We describe the successful use of EUS-FNA in a peritoneal dialysis (PD) patient to evaluate a pancreatic cyst. The patient continued on PD immediately after the procedure without using hemodialysis. The patient did not experience any complication such as infection, bleeding, or peritoneal fluid leakage.

Lumen-apposing metal stents in management of pancreatic fluid collections: The nobody's land of removal timing.

Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

Overview and comparison of guidelines for management of pancreatic cystic neoplasms.

Pancreatic cysts are identified at an increasing frequency. Although mucinous cystic neoplasms represent a pre-malignant condition, the majority of these lesions do not progress to cancer. Over the last 10 years several societies have established guidelines for the diagnosis, initial evaluation and surveillance of these lesions. Here we provide an overview of five commonly used guidelines: 2015 American Gastroenterological Association, 2017 International Association of Pancreatology, American College of Gastroenterology 2018, European Study Group and American College of Radiology. We describe the similarities and differences between the methods used to formulate these guidelines, the population they target and their approaches towards initial evaluation and surveillance of cystic lesions.

Age and cystic size are associated with clinical impact of endoscopic ultrasonography-guided fine-needle aspiration on the management of pancreatic cystic neoplasms.

Objectives: The clinical impact of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) in managing pancreatic cystic neoplasms (PCNs) remains controversial. The aim of this study was to identify which patients with PCNs would benefit from EUS-FNA. Methods: A retrospective study was performed on patients with PCNs who underwent EUS-FNA between January 2009 and June 2018. A discordant or a consistent diagnosis after EUS-FNA was analyzed and was correlated with the clinical demographic data and cystic features. Predictors of the change in the diagnosis after EUS-FNA were analyzed. Results: One hundred eighty-eight cases of PCNs were analyzed. EUS-FNA changed the diagnosis in 45.7% of all patients with PCNs and 54.5% patients with presumed branch ductal type intraductal papillary mucinous neoplasm (BD-IPMN) and impacted the recommendation in 35.6% of patients with PCNs and 50.5% patients with BD-IPMN. Patients with a discordant diagnosis after EUS-FNA were younger in age (54.8 ± 12.6 vs. 61.2 ± 14.2; p=.037) and had a cyst size larger than 3 cm than patients with a consistent diagnosis after EUS-FNA. The only worrisome feature (WF) that differed between patients with a discordant and a consistent diagnosis after EUS-FNA was the main pancreatic duct (MPD) between 5 and 9 mm (p=.013). In multivariate analysis, a cyst size >3 cm and age were independent predictors of diagnostic changes after EUS-FNA (OR: 5.33, 95% CI: 1.79-15.88, p = .003; OR: 0.96, 95% CI: 0.93-0.99, p = .031). Conclusions: EUS-FNA made a significant change in the management of nearly half of the patients with PCNs, especially in younger patients and in patients with a cyst size larger than 3 cm.

Pseudo to pseudo connection: pseudoaneurysm draining into the pseudocyst causing pseudohaemobillia.

Haemosuccus pancreaticus (HP) is an exceedingly rare cause of lower gastrointestinal (GI) bleed where pseudoaneurysm of the peripancreatic vessels ruptures into a pancreatic pseudocyst and blood travel through the pancreatic duct, thereby, draining into GI tract via the ampulla of Vater. 1 We present a case of 65-year-old African-American woman with a history of alcohol abuse presented with melena for 1 day. The contrast-enhanced CT of abdomen/pelvis showed peripancreatic vascular pseudoaneurysm with active haemorrhage. Angiography confirmed the diagnosis of HP and successful transcatheter embolisation was performed.

Next generation sequencing of the cellular and liquid fraction of pancreatic cyst fluid supports discrimination of IPMN from pseudocysts and reveals cases with multiple mutated driver clones: First findings from the prospective ZYSTEUS biomarker study.

Approximately half of all pancreatic cysts are neoplastic, mainly comprising intraductal papillary mucinous neoplasms (IPMN), which can progress to invasive carcinoma. Current Fukuoka guidelines have limited sensitivity and specificity in predicting progression of asymptomatic pancreatic cysts. We present first results of the prospective ZYSTEUS biomarker study investigating (i) whether detection of driver mutations in IPMN by liquid biopsy is technically feasible, (ii) which compartment of IPMN is most suitable for analysis, and (iii) implications for clinical diagnostics. Twenty-two patients with clinical inclusion criteria were enrolled in ZYSTEUS. Fifteen cases underwent endoscopic ultrasound (EUS)-guided fine-needle aspiration and cytological diagnostics. Cellular and liquid fraction of the cysts of each case were separated and subjected to deep targeted next generation sequencing (NGS). Clinical parameters, imaging findings (EUS and MRI), and follow-up data were collected continuously. All IPMN cases (n = 12) showed at least one mutation in either KRAS (n = 11) or GNAS (n = 4). Three cases showed both KRAS and GNAS mutations. Six cases harbored multiple KRAS/GNAS mutations. In the three cases with pseudocysts, no KRAS or GNAS mutations were detected. DNA yields were higher and showed higher mutation diversity in the cellular fraction. In conclusion, mutation detection in pancreatic cyst fluid is technically feasible with more robust results in the cellular than in the liquid fraction. Current results suggest that, together with imaging, targeted sequencing supports discrimination of IPMN from pseudocysts. The prospective design of ZYSTEUS will provide insight into diagnostic value of NGS in preoperative risk stratification. Our data provide evidence for an oligoclonal nature of IPMN.

[Gastric intramural pseudocyst in a heterotopic pancreas causing gastric outlet obstruction. Report of one case]. / Pseudoquiste pancreático intramural gástrico en páncreas heterotópico, una causa infrecuente de retención gástrica. Caso clínico.

Heterotopic pancreas is a silent gastrointestinal malformation that may become clinically evident when complicated by inflammation and pseudocyst formation. We report a 26 year-old male presenting with vomiting, pain and abdominal distention. An abdominal CT scan showed an important gastric distention secondary to a 4-cm cystic lesion located in the antrum wall. An endosonography showed that the lesion obstructed the gastric outlet and was compatible with a pseudocyst. A cysto-gastrostomy was performed draining the cyst. Its high lipase and amylase content confirmed that it was a pancreatic pseudocyst. Six months later, the lesion appeared again and a subtotal gastrectomy was performed Histopathology confirmed ectopic pancreatic tissue.

[Treatment of Pancreatic Fluid Collections].

Pancreatic Fluid Collection (PFC) develops as a result of acute pancreatitis, chronic pancreatitis, trauma, and postoperation. Although percutaneous drainage, surgery and Endoscopic Retrograde Panceatogram are used as conventional treatments in complicated PFC, the clinical course of PFC is unsatisfactory due to its clinical success rate and the risk of procedure-related complications. Endoscopic ultrasonography-guided transmural drainage of PFC is a safe and effective modality for the management of PFC, particularly in patients with pancreas necrosis. A range of techniques and stents have been introduced and a newly designed metal stent is now available.