Measuring optimal ultrasound speed using endoscopic ultrasound in patients with chronic pancreatitis, including early stage.

OBJECTIVES: Ultrasound speed (USS) correction improves image quality by estimating the optimal USS correcting the deviation from a predetermined USS. This study assessed USS differences between chronic pancreatitis (CP), early CP (ECP), and normal pancreas when using endoscopic ultrasound (EUS). The usefulness of measuring optimal USS was evaluated for patients with CP, including early stage patients. METHODS: This study enrolled 116 consecutive patients for whom USS was measured using an EUS system. The USS correction principle is generation of a B-mode image by changing the USS in all ranges while correcting the delay in the received data. Final diagnoses were made according to the Japanese diagnostic criteria for CP in 2019. They were classified as CP, ECP, or normal. We compared USS applied for these three groups. RESULTS: The medians and ranges of USS values for patients in the normal, ECP, and CP groups were 1506.0 (1407-1600) m/s, 1580.0 (1520-1630) m/s, and 1574.0 (1537-1610) m/s, respectively. The USS values of the ECP and CP groups were significantly higher than those of the normal group (P < 0.001). Analyses of the receiver operating characteristic curve in the normal pancreas, ECP, and CP revealed the area as 0.957, with specificity and sensitivity of 95.9% and 87.5%, respectively, using the USS of 1535 m/s as a cut-off. CONCLUSION: Measurement of USS might be particularly useful for distinguishing between normal and ECP imaging.

Usefulness of cytological diagnosis in pancreatic endoscopic ultrasound-guided fine needle aspiration or biopsy: Comparison with histological diagnosis and relationship with puncture route and sample acquisition method.

BACKGROUND: The purpose of this study was to clarify the role of cytology when using endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA/FNB) for pancreatic lesions by comparison with histology, and also to examine differences in diagnostic accuracy depending on the puncture route and sample acquisition method. METHODS: We studied 146 cases in which cytology and histology were performed when undertaking pancreatic EUS-FNA/FNB and the final histological diagnosis was obtained from surgically resected samples. Cytological, histological, and combined diagnoses with cytology and histology (combined diagnosis) detected malignant including suspected malignancy, indeterminate, and benign lesions. RESULTS: The accuracy of both cytology and histology in pancreatic EUS-FNA/FNB was 80.1%, with the combined diagnosis having an improved accuracy of 88.4%. The accuracy obtained with cytology was 80.0% for trans-duodenal puncture samples and 80.3% for trans-gastric puncture samples, with no difference between them. By contrast, the accuracy obtained with histology was 76.5% for trans-duodenal samples and 85.2% for trans-gastric samples, and they differed depending on the puncture route. The cytology accuracy was 80.9% for FNA and 79.8% for FNB, while the histology accuracy was 72.3% for FNA and 83.8% for FNB. CONCLUSIONS: Combining cytological diagnosis with histological diagnosis improved the diagnostic accuracy of EUS-FNA/FNB. Compared with histological diagnosis, cytological diagnosis showed stable diagnostic accuracy without being affected by differences in the puncture route or sample acquisition method.

Diagnosing chronic pancreatitis by endoscopic ultrasound assessing the association between ultrasound and pathological findings: A narrative review.

Endoscopic ultrasound (EUS) is widely recognized for its non-invasiveness and for its usefulness in chronic pancreatitis (CP) diagnosis, including early CP. Although it is desirable to obtain a definitive diagnosis of CP by tissue sampling with EUS-guided fine needle aspiration, histopathological changes in CP are heterogeneous in terms of the extent and the distribution of lesions. Therefore, histopathological diagnosis of appropriate tissue sampling by EUS-fine needle aspiration is expected to be difficult. Furthermore, it is virtually impossible to match EUS images with pathological sections, making direct contrast between EUS findings and pathology difficult. This narrative review presents a discussion of the diagnosis of CP/early CP by EUS, particularly assessing the association between ultrasound and pathological findings. Recently, the histological corroboration and correlation of EUS findings related to CP have been clarified by surgical specimens, including those obtained from animal studies. Furthermore, remarkable advances have occurred in the objective and quantitative diagnosis of pancreatic fibrosis by EUS-elastography. Future technological advances in EUS are expected to improve the accuracy of diagnosis of pancreatic fibrosis at earlier stages.

A case in which the tip of a plastic stent placed to prevent recurrence of walled-off necrosis penetrated the bile duct and formed a stent-stone complex.

A woman in her 60s underwent endoscopic sphincterotomy for choledocholithiasis. Unfortunately, post-endoscopic retrograde cholangiopancreatography pancreatitis occurred. In addition, huge walled-off necrosis (WON) appeared as a late complication. For the infected WON, endoscopic ultrasound-guided fistuloplasty and endoscopic necrosectomy were performed, and a double pigtail plastic stent (PS) (7Fr, 7 cm) was placed to prevent a recurrence. Plain computed tomography conducted two years later showed that the stent implanted for WON had deviated. The distal end of the stent was found to have migrated into the bile duct. In addition, common bile duct stones with stents as nuclei were observed. Upon performing endoscopic retrograde cholangiography, it was revealed that the stent tip perforated the distal bile duct just above the papilla. After removal of the stent using grasping forceps, we made an incision between the duodenal - bile duct fistula and bile duct orifice using a sphincterotome. Then, the stone was removed by a balloon catheter. Although such late adverse events are rare occurrences, placement of long-term PS after treatment of WON should be followed up regularly with imaging examination, and if there is no recurrence for several months, removal of the PS at that point may be considered.

Investigating COVID-19 Pandemic Effects on Acute Pancreatitis Development-From the Perspective of Alcohol Sales (Consumption) in a Japanese Regional Hospital.

[Aim and Background] People's lifestyles changed considerably due to the coronavirus disease 2019 (COVID-19) pandemic. The number of patients with acute pancreatitis (AP) can be expected to decrease as alcohol consumption decreases. This study was conducted to assess COVID-19 pandemic effects on AP patients in a Japanese regional hospital. [Methods] Based on the first and second states of emergency declarations in Tochigi Prefecture, the survey periods were set as follows: period A, 16 April-14 May; period B, 15 May-13 January; period C, 14 January-7 February; and period D, 8 February-15 April. Using data acquired in 2017, 2018, 2019, and 2020, we retrospectively reviewed the number of patients admitted to our hospital with a diagnosis of AP, and their clinical characteristics. [Results] According to a National Tax Agency survey, the average alcohol sales per adult in Tochigi Prefecture were 71.3 L in 2017 before the pandemic, and 64.0 L in 2021 under the pandemic. The number of AP patients in 2020 was 38% lower than in 2017. Comparing 2017 with 2020, the number of alcoholic AP patients was lower in 2020 (p = 0.007). [Conclusions] The findings suggest that COVID-19-pandemic-related lifestyle changes contributed to the decrease in AP patients.

Proposal and Validation of New Diagnostic Criteria for Diagnostic Weights of Endoultrasonographic Findings for Early Chronic Pancreatitis.

[Background and study aim] A commonly applied method for diagnosing chronic pancreatitis (CP) uses endoscopic ultrasonography (EUS), assigning weights to each EUS diagnostic finding. It is the Rosemont classification (RC). In 2019, to improve EUS diagnostic specificity, Japanese diagnostic criteria for early chronic pancreatitis (ECP) were revised. Nevertheless, the criteria use no weighting of EUS diagnostic findings, as the RC does. This study was undertaken to propose diagnostic criteria that would weight each EUS finding of ECP and that would be more specific than the RC. [Methods] By EUS of the pancreas, 773 patients underwent detailed observation from January 2018 to March 2019 at our institution. An expert finalized all cases when patients were diagnosed. Using data from the medical records, 97 consecutive patients with EUS diagnostic findings of ECP based on the Japanese diagnostic criteria of ECP2009 (JDCECP2009) were selected. The definition under the RC of "Indeterminate for CP" was equivalent to ECP. Each case was diagnosed using (1) JDCECP2009 and (2) the Japanese diagnostic criteria of ECP2019 (JDCECP2019). Moreover, the four diagnostic EUS findings in JDCECP2019 were applied to the RC, weighted (modified-JDCECP2019), and subsequently compared with the earlier diagnostic criteria. As Modified-JDCECP2019, we suggested (3) RC-A-the current four items scored related to the RC, and (4) RC-B-the five items scored by dividing lobularity with and without honeycombing. [Results] Diagnoses produced based on each criterion were normal: ECP = (1) 20:77, (2) 46:51, (3) 52:42, and (4) 60:35. [Conclusions] Modified-JDCECP2019 may provide EUS diagnoses for ECP with higher specificity.

The Risk of Bleeding in Small/Straight Esophageal Varices with Red Color Sign on Endoscopy: A Retrospective Analysis from the Natural Course.

Red color sign-positive (RC-positive) esophageal varices present a high bleeding risk, necessitating prophylactic treatment. Among RC-positive esophageal varices, those classified morphologically as small straight varices (Form level 1: F1) are difficult to treat. Moreover, the appropriate time for therapeutic intervention remains undefined. This study assessed the bleeding risk in RC-positive F1 esophageal varices. After extracting 541 cases of F1 esophageal varices diagnosed during 1 January 2012−29 February 2020, 76 cases of RC-positive F1 esophageal varices were divided into two groups in terms of treatment intervention at diagnosis: 49 cases with (treatment group) and 27 cases without (follow-up group). We assessed the bleeding rates, bleeding-associated factors, and early-bleeding-associated factors. The treatment group's bleeding rate was 10% (5/49). The follow-up group's bleeding rate was 78% (21/24). The subsequent bleeding rate was low in the treatment group (p < 0.001). The median period of sustained absence of bleeding was longer in the treatment group than in the follow-up group (1156 [274−1582] days vs. 105 [1−336] days; p < 0.001). In the follow-up group, a significant number of bleedings had varices that included a hematocystic spot (HCS) as RC or combined with RC (p = 0.017). Early bleeding occurred often in varices that included HCS or combined with RC (p = 0.024). Red wale marking (RWM) only was not a factor of early bleeding (p = 0.012). In conclusion, RC-positive varices should be treated even as F1 varices. Patients with RWM only show the possibility of not accepting early treatment intervention. A fast response is crucially important in HCS cases because of its associated bleeding and early bleeding.

Usefulness of Adding Maspin Staining to p53 Staining for EUS-FNA Specimens of Pancreatic Ductal Adenocarcinoma.

Background: Endoscopic ultrasound-guided puncture aspiration biopsy (EUS-FNA) of pancreatic ductal adenocarcinoma (PDAC) is highly diagnostic, but it is difficult to distinguish from benign disease. Our objective was to determine the usefulness of maspin staining, in addition to conventional p53 staining, in the diagnosis of PDAC by EUS-FNA. Methods: Of the patients who underwent EUS-FNA and were diagnosed with PDAC, we retrospectively identified 90 cases in which both maspin and p53 staining were performed. In addition, we identified 28 cases of benign pancreatic disease diagnosed using EUS-FNA and these were selected as a control group. For analysis of EUS-FNA specimens, Cohen's Kappa (κ) coefficient and the prevalence and bias adjusted Kappa statistic (PABAK) were applied to assess the significance of sensitivity and specificity, comparing p53, maspin, p53+maspin. Results: The sensitivity and specificity of p53 staining were 48.9% and 100%. The κ coefficient was 0.31 (95%CI 0.18−0.44) (p < 0.01) and the PABAK coefficient was 0.22 (95%CI 0.03−0.40). The results for maspin staining were 88.9% and 92.9%. The κ coefficient was 0.72 (95%CI 0.54−0.90) (p < 0.01) and the PABAK coefficient was 0.78 (95%CI 0.64−0.88). The results for the combination of maspin and p53 staining were 94.4% and 92.2%. The κ coefficient was 0.82 (95%CI 0.64−1.00) (p < 0.01) and the PABAK coefficient was 0.86 (95%CI 0.74−0.94). Conclusion: Adding maspin staining to p53 staining showed high sensitivity and specificity. Our results demonstrated the usefulness of their combined use that might contribute to the improvement of tissue diagnostic performance of PDAC by EUS-FNA.

Recent Advances in Endosonography-Elastography: Literature Review.

Ultrasonographic elastography is a modality used to visualize the elastic properties of tissues. Technological advances in ultrasound equipment have supported the evaluation of elastography (EG) in endosonography (EUS). Currently, the usefulness of not only EUS-strain elastography (EUS-SE) but also EUS-shear wave elastography (EUS-SWE) has been reported. We reviewed the literature on the usefulness of EUS-EG for various diseases such as chronic pancreatitis, pancreatic solid lesion, autoimmune pancreatitis, lymph node, and gastrointestinal and subepithelial lesions. The importance of this new diagnostic parameter, "tissue elasticity" in clinical practice might be applied not only to the diagnosis of liver fibrosis but also to the elucidation of the pathogeneses of various gastrointestinal diseases, including pancreatic diseases, and to the evaluation of therapeutic effects. The most important feature of EUS-EG is that it is a non-invasive modality. This is an advantage not found in EUS-guided fine needle aspiration (EUS-FNA), which has made remarkable progress in the field of diagnostics in recent years. Further development of artificial intelligence (AI) is expected to improve the diagnostic performance of EUS-EG. Future research on EUS-EG is anticipated.

Factors Affecting Technical Difficulty in Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy.

Success rates of balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) for patients with a reconstructed intestinal tract after surgical procedures are unsatisfactory. We retrospectively investigated the factors associated with unsuccessful BE-ERCP. Ninety-one patients who had a reconstructed intestinal tract after gastrectomy or choledochojejunostomy were enrolled. Age, sex, operative method, malignancy, endoscope type, endoscopist's skill, emergency procedure, and time required to reach the papilla/anastomosis were examined. The primary endpoints were the factors associated with unsuccessful BE-ERCP selective cannulation, while the secondary endpoints were the rate of reaching the papilla/anastomosis, causes of failure to reach the papilla/anastomosis, cannulation success rate, procedure success rate, and rate of adverse events. Younger age (odds ratio, 0.832; 95% CI, 0.706-0.982; p = 0.001) and Roux-en-Y partial gastrectomy (odds ratio, 54.9; 95% CI, 1.09-2763; p = 0.045) were associated with unsuccessful BE- ERCP. The rate of reaching the papilla/anastomosis was 92.3%, the success rate of biliary duct cannulation was 90.5%, procedure success rate was 78.0%, and the rate of adverse events was 5.6%. In conclusion, Roux-en-Y partial gastrectomy and younger age were associated with unsuccessful BE-ERCP. If BE-ERCP is extremely difficult to perform in such patients after Roux-en-Y partial gastrectomy, alternative procedures should be considered early.

A rare case of pulmonary lepidic metastasis in patient with branch-type intraductal papillary mucinous carcinoma of the pancreas.

Pulmonary lepidic metastasis from intraductal papillary mucinous carcinoma (IPMC) of the pancreas is extremely rare. The patient was a 50s-year old male who was hospitalized in the department of respiratory in our hospital for the evaluation of ground-glass opacities in both lungs on computed tomography (CT) imaging. Steroid therapy was administered, as interstitial pneumonia was suggested; however, there was no improvement. A transbronchial lung biopsy (TBLB) revealed the possibility of distant lung metastases. Abdominal CT revealed pancreatic cystic lesions; the patient was, therefore, referred to our department for further evaluation. Endoscopic ultrasound revealed large multi-cystic lesion with mural nodule and wall thickness. A subsequent pancreatic juice cytology under endoscopic retrograde cholangiopancreatography revealed adenocarcinoma. As this was consistent with the pathological findings shown on TBLB, IPMC metastasis to the lung was diagnosed. In this case, it was considered that pulmonary lepidic metastasis from IPMC by CT imaging and pathological findings. Although the cases of pulmonary lepidic metastasis from gastrointestinal cancer are rare, we should consider these pathological conditions when pneumonia-like infiltration observed on imaging studies does not respond to treatment.

A case report of gastric linitis plastica diagnosed by endoscopic ultrasound-guided fine needle aspiration.

RATIONALE: There is currently no consensus on the ideal method for obtaining deep tissue biopsy material of advanced gastric LP. EUS-FNA has potential as a useful diagnostic method. Thus, we report the case of a 46-year-old male with advanced gastric linitis plastica (LP) who was diagnosed using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). PATIENT CONCERNS: The patient underwent esophagogastroduodenoscopy (EGD) because of epigastric pain at a local clinic. The gastric fold swelling was pointed out by the EGD and despite the suspected advanced gastric LP, biopsy indicated Group 1. Repeat biopsy did not suggest malignancy. The patient was referred to our institution. DIAGNOSES: Endoscopic ultrasound indicated gastric wall thickening mainly in the greater curvature of the gastric corpus. Low-level echoes were detected throughout the entire gastric wall, and gastric wall layers had been disappeared. EUS-FNA of the gastric wall indicated signet ring cell carcinoma. INTERVENTIONS: As a result of EUS - FNA, it became a policy to administer chemotherapy. In accordance with the patient's wishes, he was referred to another institution for chemotherapy. OUTCOMES: Normal biopsy did not give a definitive pathological diagnosis, and final diagnosis of LP was obtained with EUS-FNA. LESSONS: We expect that EUS-FNA can be utilized as a relatively non-invasive, highly sensitive, and specific pathological diagnostic procedure for advanced gastric LP. EUS-FNA should be considered as one way to obtain a deep tissue biopsy of advanced gastric LP.