Application of artificial intelligence in pancreas endoscopic ultrasound imaging- A systematic review.

The pancreas is a vital organ in digestive system which has significant health implications. It is imperative to evaluate and identify malignant pancreatic lesions promptly in light of the high mortality rate linked to such malignancies. Endoscopic Ultrasound (EUS) is a non-invasive precise technique to detect pancreas disorders, but it is highly operator dependent. Artificial intelligence (AI), including traditional machine learning (ML) and deep learning (DL) techniques can play a pivotal role to enhancing the performance of EUS regardless of operator. AI performs a critical function in the detection, classification, and segmentation of medical images. The utilization of AI-assisted systems has improved the accuracy and productivity of pancreatic analysis, including the detection of diverse pancreatic disorders (e.g., pancreatitis, masses, and cysts) as well as landmarks and parenchyma. This systematic review examines the rapidly developing domain of AI-assisted system in EUS of the pancreas. Its objective is to present a thorough study of the present research status and developments in this area. This paper explores the significant challenges of AI-assisted system in pancreas EUS imaging, highlights the potential of AI techniques in addressing these challenges, and suggests the scope for future research in domain of AI-assisted EUS systems.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Prediction of pancreatic fibrosis by dual-energy CT-derived extracellular volume fraction: Comparison with MRI.

OBJECTIVES: To investigate the correlation between dual-energy CT (DECT) and MRI measurements of the extracellular volume fraction (ECV) and to assess the accuracy of both methods in predicting pancreatic fibrosis (PF). METHODS: We retrospectively analyzed 43 patients who underwent pancreatectomy and preoperative pancreatic DECT and MRI between November 2018 and May 2022. The ECV was calculated using the T1 relaxation time (for MR-ECV) or absolute enhancement (for DECT-ECV) at equilibrium phase (180 s after contrast injection in our study). Pearson coefficient and Bland-Altman analysis were used to compare the correlation between the two ECVs, Spearman correlations were used to investigate the association between imaging parameters and PF, Receiver operating characteristic (ROC) curves were used to assess the diagnostic performance of the ECVs for advanced fibrosis (F2-F3), and multivariate logistic regression analysis was used to examine the relationship between PF and imaging parameters. RESULTS: There was a strong correlation between DECT- and MR-derived ECVs (r = 0.948; p < 0.001). The two ECVs were positively correlated with PF (DECT: r = 0.647, p < 0.001; MR: r = 0.614, p < 0.001), and the mean values were 0.34 ± 0.08 (range: 0.22-0.62) and 0.35 ± 0.09 (range: 0.24-0.66), respectively. The area under the operating characteristic curve (AUC) for subjects with advanced fibrosis diagnosed by ECV was 0.86 for DECT-ECV and 0.87 for MR-ECV. Multivariate logistic regression analysis showed that the DECT-ECV was an independent predictor of PF. CONCLUSIONS: The ECV could be an effective predictor of histological fibrosis, and DECT is equivalent to MRI for characterizing pancreatic ECV changes.

Endoscopic retrograde cholangiopancreatography training and education.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used to diagnose and treat biliary and pancreatic diseases. It is one of the most technically demanding endoscopic procedures. ERCP training programs must ensure trainees have adequate knowledge of the anatomy and physiology associated with biliopancreatic diseases. The variety of ERCP procedures included in training programs should provide sufficient basic training for novice trainees and advanced training for experienced endoscopists. The main endoscopic procedures should be trained in ascending order of difficulty. Incorporating models capable of simulating various clinical and anatomical conditions could provide an effective means of fulfilling training requirements, although they are not easily available due to expensive facilities and void of standard assessment. Competency assessment is crucial in ERCP training to ensure trainees can independently and safely perform ERCP. Because of the rapid advancement of diagnostic and therapeutic methods, postgraduate training is critical for ERCP practitioners. Once certificates are attained, practitioners are solely responsible for maintaining their competency, credentialing, and quality.

Quantitative Magnetic Resonance Imaging for the Pancreas: Current Status.

ABSTRACT: Magnetic resonance imaging (MRI) is important for evaluating pancreatic disorders, and anatomical landmarks play a major role in the interpretation of results. Quantitative MRI is an effective diagnostic modality for various pathologic conditions, as it allows the investigation of various physical parameters. Recent advancements in quantitative MRI techniques have significantly improved the accuracy of pancreatic MRI. Consequently, this method has become an essential tool for the diagnosis, treatment, and monitoring of pancreatic diseases. This comprehensive review article presents the currently available evidence on the clinical utility of quantitative MRI of the pancreas.

Peripancreatic tuberculosis.

Peripancreatic tuberculosis (PTB) is a very rare variant of tuberculosis and its clinical and radiological findings are similar to those of pancreatic malignancy. Diagnosis of PTB is usually incidental and is made after surgical resection. We are presenting a male patient who had complaints of prolonged fever, significant weight loss and yellowish discolouration of eyes and dark-coloured urine. Investigations revealed that there was a pancreatic mass causing obstructive jaundice. However, the aetiology of the mass, whether tubercular or malignant, was not clear. Hence, the patient was planned for endoscopic ultrasound-guided fine needle aspiration cytology. Cytology and aspirate were sent for a cartridge-based nucleic acid amplification test which revealed the presence of Mycobacterium tuberculosis, sensitive to rifampicin. The patient improved completely after treatment with antitubercular therapy.

[Current CT developments in imaging of pancreatic diseases]. / Aktuelle CT-Entwicklungen für die Diagnostik von Erkrankungen des Pankreas.

BACKGROUND: Diseases of the pancreas are often diagnosed late and can have fatal consequences for patients. PURPOSE: Current computed tomography (CT) developments in imaging of pancreatic diseases. MATERIALS AND METHODS: Evaluation of numerous studies, especially considering modern CT techniques such as dual-energy CT and photon-counting CT but also artificial intelligence (AI) algorithms for disease detection. RESULTS: Spectral imaging using dual-energy CT and photon-counting CT offers numerous advantages in the detection of pancreatic disease and can thus improve diagnostic performance but also provide additional information on any therapeutic response. Likewise, advances in the development of AI algorithms are improving diagnostic performance. CONCLUSION: In the future, we can expect increasingly improved detection of pancreatic diseases, thereby enabling patients to be treated more quickly, which will consequently result in improved outcomes.

Progress in the application of dual-energy CT in pancreatic diseases.

Pancreatic diseases are difficult to diagnose due to their insidious onset and complex pathophysiological developmental characteristics. In recent years, dual-energy computed tomography (DECT) imaging technology has rapidly advanced. DECT can quantitatively extract and analyze medical imaging features and establish a correlation between these features and clinical results. This feature enables the adoption of more modern and accurate clinical diagnosis and treatment strategies for patients with pancreatic diseases so as to achieve the goal of non-invasive, low-cost, and personalized treatment. The purpose of this review is to elaborate on the application of DECT for the diagnosis, biological characterization, and prediction of the survival of patients with pancreatic diseases (including pancreatitis, pancreatic cancer, pancreatic cystic tumor, pancreatic neuroendocrine tumor, and pancreatic injury) and to summarize its current limitations and future research prospects.

Evolution of Pancreatic Endotherapy.

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

Pancreatic steatosis and iron overload increases cardiovascular risk in non-alcoholic fatty liver disease.

Objective: To assess the prevalence of pancreatic steatosis and iron overload in non-alcoholic fatty liver disease (NAFLD) and their correlation with liver histology severity and the risk of cardiometabolic diseases. Method: A prospective, multicenter study including NAFLD patients with biopsy and paired Magnetic Resonance Imaging (MRI) was performed. Liver biopsies were evaluated according to NASH Clinical Research Network, hepatic iron storages were scored, and digital pathology quantified the tissue proportionate areas of fat and iron. MRI-biomarkers of fat fraction (PDFF) and iron accumulation (R2*) were obtained from the liver and pancreas. Different metabolic traits were evaluated, cardiovascular disease (CVD) risk was estimated with the atherosclerotic CVD score, and the severity of iron metabolism alteration was determined by grading metabolic hiperferritinemia (MHF). Associations between CVD, histology and MRI were investigated. Results: In total, 324 patients were included. MRI-determined pancreatic iron overload and moderate-to severe steatosis were present in 45% and 25%, respectively. Liver and pancreatic MRI-biomarkers showed a weak correlation (r=0.32 for PDFF, r=0.17 for R2*). Pancreatic PDFF increased with hepatic histologic steatosis grades and NASH diagnosis (p<0.001). Prevalence of pancreatic steatosis and iron overload increased with the number of metabolic traits (p<0.001). Liver R2* significantly correlated with MHF (AUC=0.77 [0.72-0.82]). MRI-determined pancreatic steatosis (OR=3.15 [1.63-6.09]), and iron overload (OR=2.39 [1.32-4.37]) were independently associated with high-risk CVD. Histologic diagnosis of NASH and advanced fibrosis were also associated with high-risk CVD. Conclusion: Pancreatic steatosis and iron overload could be of utility in clinical decision-making and prognostication of NAFLD.

Isolated pancreatic tuberculosis masquerading as malignancy in an immunocompetent host: a case report and review of the literature.

A 41-year-old man was admitted to our department with a 7-day history of jaundice of the skin. He was misdiagnosed with carcinoma because imaging tests showed a space-occupying lesion in the pancreatic head, and laboratory examinations showed elevated liver enzymes, and elevated serum bilirubin, alpha-fetoprotein, carbohydrate antigen 19-9, and ferroprotein levels. However, there was slight calcification in the lesion and a subsequent T-Spot test result was positive. The patient then underwent endoscopic retrograde cholangiopancreatography for biopsy and bile drainage. Histologically, the pancreatic mass showed granulomatosis, and the pathologic diagnosis of the isolated pancreatic neoplasm was tuberculosis. The patient accordingly received anti-tuberculosis agents, resulting in a significant decrease in the size of the pancreatic mass. The patient recovered well. Pancreatic tuberculosis can masquerade as malignancy; however, careful attention to a differential diagnosis can prevent the need for laparotomy.

Endoscopic Management of Necrotic Pancreatic Fluid Collections in the Setting of Disrupted Pancreatic Duct Syndrome: Out Like a LAMS?

In this commentary, the recent study "Safety and Efficacy of Long-Term Transmural Plastic Stent Placement After Removal of Lumen Apposing Metal Stent In Resolved Pancreatic Fluid Collections With Duct Disconnection at Head/Neck of Pancreas" is addressed. Some background information regarding endoscopic management of walled off necrosis is mentioned, then the study is summarized, followed by a critique about the strengths and limitations of the study. Further areas of research are also mentioned.

Challenging Diagnosis of Intrapancreatic Accessory Spleen in the Tail of the Pancreas: A Case Report.

BACKGROUND Intrapancreatic accessory spleen, or splenunculus, is a congenital condition that occurs in up to 2% of the population, with the tail of the pancreas being the second most common site. Imaging alone may not confirm the diagnosis as this can mimic a hypervascular tumor on contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). This report presents a challenging case of intrapancreatic accessory spleen in the tail of the pancreas in a 64-year-old man. CASE REPORT A 64-year-old man was admitted for a space-occupying lesion in the tail of the pancreas. CT, MRI, and positron emission tomography-CT could not confirm the diagnosis. Endoscopic ultrasound-guided fine-needle aspiration biopsy was not performed given the potential for greater risk. The mass in the patient's pancreatic tail was considered benign or low-grade malignant. The patient then underwent a robotic pancreatectomy to remove the tumor in the tail of the pancreas. We performed intraoperative ultrasound scanning and detected a hypoechoic nodule in the body of the pancreas. This nodule had a clear boundary, and color Doppler flow imaging showed that there was no definite blood flow signal in it. The pathology diagnosis after surgery was intrapancreatic accessory spleen. The patient recovered without other complications and was discharged 5 days later. CONCLUSIONS This report highlights the importance of considering the diagnosis of intrapancreatic accessory spleen in hypervascular lesions seen on imaging alone and of confirming the diagnosis with definitive cytopathology or histopathology.

Artificial intelligence assisted whole organ pancreatic fat estimation on magnetic resonance imaging and correlation with pancreas attenuation on computed tomography.

BACKGROUND: Fatty pancreas is associated with inflammatory and neoplastic pancreatic diseases. Magnetic resonance imaging (MRI) is the diagnostic modality of choice for measuring pancreatic fat. Measurements typically use regions of interest limited by sampling and variability. We have previously described an artificial intelligence (AI)-aided approach for whole pancreas fat estimation on computed tomography (CT). In this study, we aimed to assess the correlation between whole pancreas MRI proton-density fat fraction (MR-PDFF) and CT attenuation. METHODS: We identified patients without pancreatic disease who underwent both MRI and CT between January 1, 2015 and June 1, 2020. 158 paired MRI and CT scans were available for pancreas segmentation using an iteratively trained convolutional neural network (CNN) with manual correction. Boxplots were generated to visualize slice-by-slice variability in 2D-axial slice MR-PDFF. Correlation between whole pancreas MR-PDFF and age, BMI, hepatic fat and pancreas CT-Hounsfield Unit (CT-HU) was assessed. RESULTS: Mean pancreatic MR-PDFF showed a strong inverse correlation (Spearman -0.755) with mean CT-HU. MR-PDFF was higher in males (25.22 vs 20.87; p = 0.0015) and in subjects with diabetes mellitus (25.95 vs 22.17; p = 0.0324), and was positively correlated with age and BMI. The pancreatic 2D-axial slice-to-slice MR-PDFF variability increased with increasing mean whole pancreas MR-PDFF (Spearman 0.51; p < 0.0001). CONCLUSION: Our study demonstrates a strong inverse correlation between whole pancreas MR-PDFF and CT-HU, indicating that both imaging modalities can be used to assess pancreatic fat. 2D-axial pancreas MR-PDFF is variable across slices, underscoring the need for AI-aided whole-organ measurements for objective and reproducible estimation of pancreatic fat.