Early Endoscopic Interventions for Pancreatic Necrosis: Indications, Technique, and Outcomes.

Endoscopic transmural drainage is usually performed for symptomatic well-encapsulated walled-off necrosis (WON) that usually develops in the delayed phase (> 4 weeks after disease onset) of acute necrotising pancreatitis (ANP). Endoscopic drainage is usually not advocated in the early (< 4 weeks after disease onset) stage of illness because of the risk of complications due to an incompletely formed encapsulating wall and poor demarcation of viable from necrotic tissue. However, emerging data from expert tertiary care centres over the last few years shows that the early endoscopic transluminal drainage approach is effective and safe. The development of lumen-apposing metal stents and better accessories for endoscopic necrosectomy has fuelled the expansion of indications of endoscopic drainage of pancreatic necrosis. However, early endoscopic drainage is associated with higher rates of adverse events; therefore, careful patient selection is paramount. This article will review the current indications, techniques and outcomes of early endoscopic transluminal drainage in pancreatic necrotic collections.

Modified trichrome stain for faster and improved detection of intestinal protozoan parasites.

Permanent stains such as trichrome have better sensitivity but are time-consuming and the fixative includes toxic mercuric chloride. Thus, a newer modification was tested and found to be a superior, faster and safer staining technique for intestinal parasitic detection. Our study lasted 9 months and a single stool sample was collected from each enrolled patient. We evaluated classical trichrome (T1 - using Schaudinn fixative) with newer modifications, which involved different fixatives with mordant combinations (T2 - acetic acid + hydrated aluminium sulphate, T3 - citric acid + copper sulphate hydrate). Conventional PCR targeting Entamoeba histolytica, Giardia lamblia and Cryptosporidium spp. was taken as the reference. Out of 175 stool samples, 25.1% protozoa were identified by wet mount, 24% by each T1 and T2, 25.7% by T3. Statistically, T3 and T2 had higher sensitivity as compared to T1 and wet mount when PCR was used as reference.

Current paradigm of endoscopic ultrasound in biliary and pancreatic duct drainage: an update.

Endoscopic retrograde cholangiopancreatography (ERCP) is the workhorse for biliary and pancreatic ductal interventions. Despite advances in both endoscopes and accessories for ERCP, it still has limitations in the presence of altered anatomy, luminal obstruction hindering access to the papilla, and proximal duct obstructions by tight stricture, calculi or intraductal growth. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and EUS-guided pancreatic duct drainage (EUS-PDD) have expanded the rescue procedures after failed ERCP. This review discusses the techniques and results of various EUS-BD procedures, as well as EUS-PDD.

Simultaneous Integrated Boost (SIB) Versus Sequential Boost in Anal Cancer Patients: A Single-Center Experience.

PURPOSE: Concurrent chemoradiation is the standard of care for the treatment of anal cancer. Radiation can be delivered by sequential or simultaneous integrated boost (SIB) approach. The present study was conducted to compare the treatment outcomes and toxicity profile of patients with anal cancer treated with sequential boost and SIB approach. METHODS: A single-institution retrospective analysis of patients with squamous cell carcinoma of the anal canal treated between 2019 and 2022 with radical chemoradiation was performed. The sequential boost schedule consisted of 45 Gy in 25 fractions (1.8 Gy daily) to the gross tumor, nodes, and elective nodal volume, followed by a 9 Gy in five fractions boost to the gross disease. Patients receiving SIB were treated as per RTOG 0529 protocol. In both the groups, patients were treated with volumetric modulated arc therapy (VMAT). The two groups were compared in terms of overall survival (OS), colostomy-free survival (CFS), relapse-free survival (RFS), and acute toxicity profile. p-values < 0.05 were considered statistically significant. RESULTS: The patient and disease characteristics in both treatment arms were comparable. The only difference was a significantly longer overall treatment time of ≥ 50 days in the sequential arm (77.8% vs 43.8%, p = 0.04). The median follow-up was 18 months. The 2-year CFS was 80% in sequential vs 87.5% at 2 years for the SIB arm, 2-year OS 83.3% vs 58.6%, and 2-year RFS was 38.9% vs 41.7%, respectively. A total of 14 (77.8%) in sequential and 8 (50%) in the SIB arm had disease relapse. On univariate analysis, the involved pelvic lymph node significantly affected OS (HR 10.45, p = 0.03) while inguinal lymph node involvement adversely affected RFS (HR 6.16, p = 0.02). The most common acute toxicity was radiation-induced dermatitis, 15 (83.4%; 5 grade II, 10 grade III) in sequential vs 7 (43.8%; 3 each grade II and III) in the SIB group followed by hematological (61.1% vs 68.75%). However, the incidence of overall acute toxicities was significantly less in the SIB arm (p = 0.006). CONCLUSION: Our study showed that concurrent chemoradiation with the SIB-VMAT approach is well tolerated in patients of anal carcinoma and resulted in lesser treatment interruptions and comparable outcomes as compared to the sequential approach. Our results warrant further evaluation in a prospective study.

The WHO system versus the Papanicolaou society of cytopathology system for reporting pancreaticobiliary cytology for risk stratification-which is better?

BACKGROUND: Recently, the World Health Organization (WHO) has proposed a reporting system for pancreaticobiliary cytopathology. We applied this classification for pancreatic lesion samples by fine needle aspiration (FNA) and compared the results to the previous classification of the Papanicolaou Society of Cytopathology (PSC) system for risk stratification. METHODS: The computerized database was searched for all pancreatic endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and transabdominal ultrasound-guided FNA (TUS-FNA) samples from 2016 to 2020 and cases were reassigned as per the PSC and the WHO diagnostic categories. Cases with follow-up, clinicoradiological, and/or histopathology were included in the study. The risk of malignancy (ROM) was calculated across all diagnostic categories based on clinical data, imaging data, and histopathology wherever available. RESULTS: There were a total of 625 pancreatic FNA. In 230 cases, follow-up information was available which included 116 EUS and 114 TUS-FNA samples. The ROM for PSC categories I-VI was 40%, 19.7%, 28.6%, 57.1%, 94.7%, and 97.9% and for the WHO categories (I-VII), it was 60%, 21.3%, and 35.7%, not representative, not applicable, 94.7% and 94.9%. The overall sensitivity and specificity of PSC was 68.2% and 96.2% when categories V and VI were taken as positive and 78.9% and 93.3% for WHO when categories VI and VII were taken as positive. CONCLUSIONS: Pancreatic FNA samples reported as per the WHO system showed better sensitivity as compared to the PSC system resulting in better risk stratification and consequently better patient management. The overall high specificity and moderate sensitivity reaffirm the utility of FNA in pancreatic lesions.

Endoscopic Ultrasound in Pancreatic Duct Anomalies.

Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.

Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center.

Background: The conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method. Methods: A single-center retrospective study of the prospectively maintained database from April 2008 to December 2021. Results: A total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula. Conclusion: MIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.

Clinical spectrum & changing presentation of celiac disease in Indian children.

Background & objectives: Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation. Methods: A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed. Results: The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children. Interpretation & conclusions: This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years.

Endoscopic treatment of pancreatic necrosis: Still searching for perfection!

Over last few years, there has been a paradigm shift in the management of infected pancreatic necrosis with endoscopic and minimally invasive "step-up" management approach replacing open surgical necrosectomy. Because of being associated with reduced occurrence of new onset multi-organ failure, external pancreatic fistulae, shorter hospital stay, lower costs, and better quality of life compared with minimally invasive surgical approach, endoscopic "step-up" management approach is the preferred intervention for endoscopically accessible pancreatic necrotic collections at expert centers with endoscopic expertise. Development of lumen apposing metal stents and improvised accessories for interventional endoscopic ultrasound has revolutionized the endoscopic management of pancreatic necrosis making it more effective and safer. Despite these promising developments, endoscopic transluminal necrosectomy (ETN) remains the Achilles heel. Lack of dedicated endoscopic accessories, poor endoscopic visualization within the necrotic cavity, limited diameter of the instrument channel of the endoscope that is a significant impediment to remove large amount of necrotic material, and uncertain ability to avoid vessels and vital structures in the necrotic cavity are important limitations during endoscopic necrosectomy. Recent devices and solutions including use of cap assisted necrosectomy, over the scope grasper and powered endoscopic debridement device are welcome steps in our pursuit for an ideal, safer, and efficacious ETN device. This review will discuss recent advances as well as challenges in the endoscopic management of pancreatic necrosis.

EUS-guided FNAC in intra-abdominal lesions: Technique of tissue acquisition, ancillary testing, pearls and perils, and prospects.

Endoscopic ultrasound enables visualization of lesions within and in the vicinity of the gastrointestinal tract. Endoscopic ultrasound guided fine needle aspiration cytology (EUS-FNAC) helps in targeting various luminal and extraluminal lesions both diagnostically and therapeutically. Various intra-abdominal organs amenable to EUS-FNA include the gastrointestinal tract (GIT), pancreas, kidney, adrenal gland, liver, bile duct, gallbladder, spleen, and lymph nodes. EUS-FNAC is mostly done for pancreatic and intra-abdominal lymph nodal lesions. In the present review, we have discussed various aspects of EUS-FNAC.

Endoscopic Ultrasound-guided Trans-esophageal Transmural Drainage of Mediastinal Pseudocysts: A Case Series.

BACKGROUND AND AIMS: Mediastinal pseudocysts (MP) are rare, and surgery is the conventional treatment modality. However, in the last decade, excellent outcomes have been reported with endoscopic transpapillary drainage. Endoscopic ultrasound (EUS) guided trans-esophageal transmural drainage of MP is a minimally invasive and effective non-surgical treatment modality, but the experience is limited. We aimed to report our experience of EUS-guided transmural drainage in 10 patients with MP's. METHODS: A retrospective analysis of patients with pancreatic fluid collections treated with EUS-guided transmural drainage over the last ten years was completed to to identify patients with MP's. RESULTS: Ten patients (8 males, with a mean age of 34.9±9.17 years) with MP treated with EUS-guided transesophageal transmural drainage were identified. Nine patients with MP had concurrent chronic pancreatitis, and only one had MP following acute necrotizing pancreatitis. The mean size of MP was 5.70±1.64 cm, and nine patients (90%) had concurrent abdominal pseudocyst. EUS-guided transesophageal transmural drainage was technically successful in all ten patients. Transmural plastic stents were placed in 9 patients, whereas one patient underwent single-time complete aspiration of the MP. There were no immediate or delayed procedure-related complications. All ten patients had a successful outcome, with the mean resolution time being 2.80±0.79 weeks. There has been no recurrence of PFC or symptoms in nine (90%) successfully treated patients over a mean follow-up period of 43.3 months. CONCLUSIONS: EUS-guided trans-esophageal drainage of MP is safe with a high technical and clinical success rate.