Pancreatic cancer screening in high-risk individuals.

The incidence of pancreatic cancer is increasing, although globally it represents less than 3% of all cancers. Despite advances in medical and surgical management, survival rates have not significantly improved in recent years. Consequently, pancreatic cancer, though relatively uncommon, is the third leading cause of cancer-related deaths. This is primarily due to the disease´s late detection. Symptoms appear late and are nonspecific, and over 80% of cases are diagnosed at an advanced stage and unsuitable for curative surgery, resulting in a five-year survival rate below 10%. However, the exceptional cases that are diagnosed early show five-year survival rates exceeding 80%. Therefore, one of the keys to improving pancreatic cancer prognosis lies in early detection, making screening in high-risk individuals a potentially crucial strategy.

Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group from the Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines.

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past years, the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques, such as endoscopic ultrasound guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group from the Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) have the purpose to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Endoscopic Ultrasound-Guided Tissue Sampling for the Cytohistological Diagnosis of Focal Liver Lesions.

BACKGROUND: Focal liver lesions (FLL) often require cytohistological evaluation. Endoscopic Ultrasound (EUS)-guided tissue acquisition (EUS-TA) is highly accurate in diagnosing pancreatic and gastrointestinal malignancies. The aim of our study was to evaluate the role of EUS-TA in the characterization of FLL. METHODS: A retrospective analysis of a prospective database of patients who underwent EUS-TA for the evaluation of FLL. Diagnostic yield, adverse events and factors associated with diagnostic yield were evaluated as endpoints. The effect of variables such as needle size, lesion size, rapid on-site evaluation (ROSE) and the use of cytological or histological needles were analyzed. RESULTS: A total of 114 cases were included (mean age 68.05 ± 11.35 years, 64 male). A correct diagnosis was made using EUS-TA in 100 of the 114 cases (diagnostic yield of 88%). The EUS-TA of additional extrahepatic lesions during the same EUS procedure increased the diagnostic yield to 94%. No adverse events were reported. Multivariate analysis did not identify any factor influencing the diagnostic yield. CONCLUSIONS: EUS-TA is a highly accurate and safe technique for the differential diagnosis of FLL and could be considered as the primary approach in this setting.

Endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) with the Procore(TM) needle provides inadequate material for the histological diagnosis of early chronic pancreatitis

Background: diagnosis of early chronic pancreatitis (CP) is hampered due to the low accuracy of current imaging techniques and the absence of methods for histological confirmation. We aimed to evaluate the efficacy of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for the histological diagnosis of early CP. Methods: a prospective, cross-sectional, single-center study was designed. Consecutive patients referred for EUS with a clinical suspicion of CP were evaluated for inclusion into the study. Inclusion criteria were age > 18 years and indeterminate EUS findings for the diagnosis of CP according to the Rosemont classification. EUS-FNB of the body of the pancreas was performed with Procore(TM) needles. Tissue samples were immersed into a methanol-based buffered preservative solution for cytohistological evaluation. The quality of the samples obtained and the histological findings were evaluated. Procedure-related complications were recorded. Results: the study was stopped after eleven patients were included due to safety concerns and poor diagnostic yield. The mean age of the patients was 50.3 years (range 33-70 years) and six were male. Samples were of poor quality in five cases, but were sufficient for cell-block evaluation. An inflammatory infiltration with mild fibrosis was identified in two cases and neither inflammatory infiltration nor fibrosis was identified in three cases. With regard to the other six cases, isolated inflammatory cells were observed in one case, although the cellularity was poor and unsuitable for cytological evaluation in five cases. There was one major complication (9.1%) of acute pancreatitis that required hospitalization for 48 hours. Conclusion: EUS-FNB is technically feasible in patients with EUS findings categorized as indeterminate for a CP diagnosis. However, the diagnostic yield is poor and there is a non-negligible risk of complications

No disponible

Endoscopic ultrasound cytologic brushing vs endoscopic ultrasound - fine needle aspiration for cytological diagnosis of cystic pancreatic lesions. A multicenter, randomized open-label trial

Introduction: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. Objectives: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). Methods: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. Results: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). Conclusions: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA

No disponible

Últimos avances sobre los tumores pancreáticos / Latest advances in pancreatic tumours

El cáncer de páncreas continúa siendo una entidad de pésimo pronóstico. Apenas existen avances terapéuticos en los últimos años, por lo que la mayor parte del esfuerzo se centra en prevenir su aparición y diagnosticar lesiones precursoras. El uso de estatinas como factor preventivo y la implementación de programas de cribado en pacientes de alto riesgo van ganando terreno en este sentido. En el campo del tratamiento se profundiza en el papel de la terapia neoadyuvante en el cáncer de páncreas y en el abordaje multimodal de la enfermedad, con apenas avances en cuanto a terapias novedosas y eficaces. Los tumores quísticos del páncreas, en especial el tumor mucinoso papilar intraductal, con su conocido potencial de malignidad, acaparan la mayor parte de trabajos. La validación de las guías internaciones de Fukuoka 2012 y las muy controvertidas guías AGA 2015 son objeto de múltiples trabajos. Destacan los que evidencian el subóptimo valor predictivo positivo y que cuestionan aspectos muy relevantes de estas, como la discontinuación del seguimiento o los criterios de derivación quirúrgica. Entre los procedimientos diagnósticos destacan la quistoscopia y la endomicroscopía láser confocal, asociadas a la punción guiada por ecoendoscopia, como técnicas más prometedoras por su alta eficacia y valor predictivo negativo a la hora de detectar lesiones quísticas mucinosas. Los trabajos sobre historia natural de los tumores mucinosos papilares intraductales, que nos ayudan a profundizar en su conocimiento y en la búsqueda de factores predictivos de desarrollo de cáncer, también proliferan

Pancreatic cancer continues to have a bleak prognosis. Hardly any therapeutic advances have been made in the last few years and consequently most efforts have focused on preventing its development and on diagnosing precursor lesions. In this regard, the use of statins as a preventive factor and the implementation of screening programmes in high-risk patients are gaining ground. In the field of treatment, there is greater focus on the role of neoadjuvant therapy in pancreatic cancer and on a multimodal approach to the disease, with few advances in effective novel therapies. Most studies concerned cystic tumours of the pancreas, especially intraductal mucinous papillary tumour, with its known potential for malignant transformation. Multiple studies were devoted to validation of the 2012 Fukuoka international guidelines and the highly controversial 2015 AGA guidelines. Notable among these studies were those demonstrating the suboptimal positive predictive value and questioning important aspects of the guidelines, such as discontinuation of follow-up or the criteria for surgical referral. Notable among diagnostic procedures were cystoscopy and endoscopic ultrasound-guided needle-based confocal laser endomicroscopy as the most promising techniques due to their high efficacy and negative predictive value in detecting mucinous cystic lesions. There were also a large number of studies on the natural history of intraductal papillary mucinous tumours, which help deepen knowledge of these entities and the search for predictive factors of cancer development

Últimos avances en tumores pancreáticos / Latest advances in pancreatic tumours

El cáncer de páncreas continúa siendo una entidad de pésimo pronóstico. Apenas existen avances terapéuticos en los últimos años, por lo que la mayor parte del esfuerzo se centra en tratar de diagnosticar la enfermedad en un estadio precoz. En este sentido, la ultrasonografía endoscópica y diferentes herramientas asociadas a esta, como la elastografía o el uso de contrastes intravenosos, continúan siendo la piedra angular en el diagnóstico diferencial. Los tumores quísticos del páncreas, en especial el tumor papilar mucinoso intraductal, con su conocido potencial de malignidad, inundan de trabajos esta última edición de la Digestive Disease Week. Además de incidir en los problemas para su caracterización preoperatoria, tanto por la evaluación citológica por ultrasonografía endoscópica, incluso con la presencia de patólogo 'en la sala', como por el estudio de marcadores intraquísticos, se potencia el papel de otras técnicas como la endomicroscopia láser confocal o el uso de contrastes intravenosos para la caracterización del nódulo mural. Abundan los trabajos acerca de la historia natural del tumor papilar mucinoso intraductal, que en mayor medida validan el espíritu, cada vez más conservador, de las recientes guías internacionales de Fukuoka. Ciertos aspectos, como las comorbilidades, a la hora de considerar la cirugía o el ritmo de crecimiento de la neoplasia se ponen de relieve. En el campo del tratamiento comienza a tomar relevancia, en casos concretos, la inyección mediante ultrasonografía endoscópica de gemcitabina y paclitaxel sin necesidad de alcohol como tratamiento ablativo de las neoplasias quísticas mucinosas (AU)

Pancreatic cancer continues to have an extremely poor prognosis. There have been hardly any therapeutic advances in the last few years and consequently attention is focussed on early diagnosis. In this regard, endoscopic ultrasonography and several associated techniques, such as electrography or the use of intravenous contrast agents, continue to be the cornerstone of differential diagnosis. In the latest Digestive Diseases Week, numerous presentations were made on cystic pancreatic tumours, especially intraductal papillary mucinous tumours, with their well-known potential for malignant trans formation. In addition to the problems of the preoperative characterization of these entities, by both endoscopic ultrasound cytological evaluation‑even with the presence of an on-site pathologist -and by intracystic markers, the role of other techniques was also mentioned, such as confocal laser endomicroscopy or the use of intravenous contrast agents to characterize the wall nodule. There were numerous studies on the natural history of intraductal papillary mucinous tumours, which mainly supported the increasingly conservative approach adopted by the recent Fukuoka international guidelines. Certain aspects were highlighted, such as comorbidities, when considering surgery, or the growth rate of the tumour. In treatment, endoscopic ultrasound-guided injection of gemcitabine and paclitaxel, without the need for alcohol as an ablative treatment of mucinous cystic tumours, is gaining ground in specific cases (AU)

Endoscopic ultrasound in the diagnosis of chronic pancreatitis

Diagnosis of chronic pancreatitis (CP) remains a challenge. Endoscopic ultrasound (EUS) can be considered nowadays as the technique of choice for the morphological diagnosis of this disease. More than three or four EUS defined criteria of CP need to be present for the diagnosis of the disease. The development of the more restrictive Rosemont classification aims to standardize the criteria, assigning different values to different features but its impact on the EUS-based diagnosis of CP is debatable. A combined use of endoscopic function test and EUS has even increased the diagnostic yield. Elastography and FNA may be also of help for diagnosing CP. EUS also provides with very valuable information on the severity of the disease, giving key information that may influence in the treatment. Differential diagnosis of solid pancreatic masses in the context of a CP is also challenging, EUS plays a key role in this context. It provides with the possibility of obtaining specimens for histopathological diagnosis. Nowadays, new developed techniques associated to EUS, like elastography and contrast enhancement, are also showing promising results for the differentiating between these pancreatic lesions (AU)

No disponible

Feasibility of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and biopsy (FNB) with a new slim linear echoendoscope

BACKGROUND: Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) and biopsy (FNB) is considered a very accurate and safe tool for sampling extra-intestinal tumors. Standard echoendosocopes for FNA/FNB are large with a sharpened tip that can be associated with complications. A new slim linear echoendoscope have been developed trying to overcome this limitation. AIM: Of the present study was to evaluate the feasibility; safety and diagnostic yield of this newly developed slim echoendoscope for performing EUS-guided FNA/FNB. METHODS: A pilot observational study was performed. Consecutive patients submitted for a EUS-FNA/FNB were prospectively included in the study. Patients underwent EUS procedure using the new slim linear PENTAX-echoendoscope. Tissue acquisition was done with standard and histology needles. Feasibility and diagnostic yield were evaluated. A descriptive analysis was performed. RESULTS: 87 patients were included (mean age 66.7 years (range 24-90 years), 45 male. Mean size was of lesions sampled were 33.43 ± 20.8 mm. Esophagus intubation and access to the second portion of the duodenum (D2) were considered easy in all 87 cases (100%). Nineteen procedures (21.8%) were performed from the esophagus, 42 (48.3%) from the stomach, 22 (25.3%) cases from duodenal bulb, and 4 (4.6%) cases from D2. EUS-FNB was feasible in 85 cases (97.7%), failed in 2 pancreatic lesions accessed from D2. Diagnostic yield was 86.21% (95%CI 77.4- 91.9) in the intention-to-treat analysis and 88.24% (95%CI 79.7- 93.5) in per-protocol analysis. There were no complications related to the technique. CONCLUSION: Performing a EUS-FNA/FNB with the newly designed slim scope is feasible and safe for cyto-histopathology diagnosis of intra-intestinal and extra-intestinal mass lesions

No disponible

Últimos avances sobre los tumores pancreáticos / Pancreatic tumors: recent development

El cáncer de páncreas continúa siendo una entidad de pésimo pronóstico. Además del tabaco, la obesidad y la diabetes mellitus de reciente aparición emergen como importantes factores de riesgo. La ultrasonografía endoscópica continúa siendo el pilar fundamental del diagnóstico y sobre la que se sustentan la mayor parte de los avances. En este sentido cobra importancia el papel de la endomicroscopia láser confocal a través de la aguja, para el diagnóstico diferencial de las lesiones sólidas de páncreas y estudios que comparan los diferentes tipos de agujas (citología frente a histología) para la punción guiada por ultrasonografía endoscópica. El uso de contrastes endovenosos y la elastografía son otras herramientas asociadas a la ultrasonografía endoscópica que podrían contribuir en el diagnóstico del cáncer de páncreas. En cuanto a los factores pronósticos, se insiste en el papel de la resección vascular portomesentérica. Como en años anteriores, los avances en el campo del tratamiento son escasos. En relación con los tumores quísticos, los trabajos se centran en validar las nuevas guías internacionales de Fukuoka de 2012 (criterios revisados de Sendai) y en determinar los factores predictivos de malignidad de las lesiones quísticas, fundamentalmente del tumor mucinoso papilar intraductal. Desde el punto de vista terapéutico se especula sobre la utilidad del alcohol y la combinación del paclitaxel + gemcitabina en la ablación de lesiones quísticas mucinosas de pequeño tamaño a través de la inyección mediante ultrasonografía endoscópica

Pancreatic cancer (PC) still typically has a poor prognosis. In addition to smoking, obesity and new-onset diabetes mellitus are considered to be significant risk factors. An endoscopic ultrasound (EUS) remains the mainstay for diagnosis and on which the majority of advances are based. In this sense, needle-based confocal laser endomicroscopy (nCLE) is gaining importance in the differential diagnosis of solid pancreatic lesions and studies comparing different needle types (cytology vs. histology) for EUS-guided puncture. Intravenous contrast (IC-EUS) and elastography are additional tools associated with EUS that can assist in diagnosing PC. Regarding prognostic factors, the importance of the role of mesenteric-portal vein resection was emphasized, given the limited advances in treatment, as in previous years. Regarding cystic tumors, work focuses on validating the new international guidelines from Fukuoka 2012 (revised Sendai criteria) and on determining predictors of cystic lesion malignancy, mainly of intraductal papillary mucinous neoplasm (IPMN). From a therapeutic point of view, there are theories regarding the usefulness of alcohol and the gemcitabine-paclitaxel combination in the ablation of small mucinous cystic lesions through EUS-injection

Evaluation of the adequacy and diagnostic accuracy of the histology samples obtained with a newly designed 19-gauge EUS histology needle / Evaluación de la adecuación y seguridad diagnóstica de las muestras histológicas obtenidas con una aguja recientemente diseñada de 19G guiada por ecoendoscopia

Background: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is an accurate technique for sampling intraintestinal and extraintestinal lesions. However, cytology possesses certain limitations, which may be overcome if histological specimens are provided to the pathologist. Aim: The aim of the study was to evaluate the accuracy of a newly developed 19G histology needle. Methods: Retrospective analysis of a prospectively collected data base including patients who underwent EUS-guided biopsy with the 19G ProCoreTM histology needle for the evaluation of intraintestinal or extraintestinal lesions. Samples were obtained after one needle pass, recovered into ThinPrep® and processed for histological analysis. Results were compared to the gold standard of surgical histopathology, or global pathological, clinical and radiological assessment, and follow-up in non-operated cases. Results are shown as mean ± SD. Percentage of optimal samples for histological evaluation and the overall diagnostic accuracy were evaluated. Results: 87 patients (mean age 62.9 years, range 25-88 years, 36 woman) were included. Lesions mean size was 41.6 ± 21.3 mm. 66 lesions (75.9 %) were considered as malignant and 21 (24.1 %) as benign. EUS-guided biopsy was feasible in all cases (100 %). Sample quality was adequate for histological assessment in 82 lesions (94.2 %). In the remaining cases the sample was adequate for cell-block evaluation. Sensitivity, specificity, PPV, NPV, and overall accuracy for malignancy were 93.4 %, 100 %, 100 %, 84 %, and 95.4 %, respectively. There were no complications related to the procedure. Conclusion: The EUS-guided biopsy with the 19G histology needle provides with an optimal core sample for histological evaluation allowing a high histopathologic diagnostic accuracy (AU)

No disponible

Transhepatic anterograde biliary drainage using a self-expandable metallic stent: a therapeutic alternative after hepaticojejunostomy with Roux-en-Y reconstruction / Drenaje biliar transhepático anterógrado usando una prótesis metálica autoexpandible: Una alternativa terapéutica tras la hepaticoyeyunostomía con reconstrucción en Y en Roux

Endoscopic drainage is the procedure of choice in cases of obstructive jaundice. However, in patients with a surgical biliary reconstruction, this technique cannot be often satisfactorily used. In these cases, the best alternative has usually been the percutaneous biliary drainage. Since the introduction of endoscopic ultrasoundguided therapy, some new techniques have been proposed to solve these technical problems related to postsurgical disturbed anatomy. In this case report, we describe our successful experience in the performance of a transhepatic anterograde biliary drainage using a self-expandable metallic stent in the context of a patient who previously had undergone a hepaticojejunostomy with Roux-en-Y reconstruction because of a resected hilar cholangiocarcinoma (AU)

The role of endoscopic ultrasound (EUS) in relation to other imaging modalities in the differential diagnosis between mass forming chronic pancreatitis, autoimmune pancreatitis and ductal pancreatic adenocarcinoma / Papel de la endoscopia en relación con otras modalidades de imagen en el diagnóstico diferencial entre pancreatitis crónica en forma de masa, pancreatitis autoinmune y adenocarcinoma pancreático

Differential diagnosis of solid pancreatic lesions remains as an important clinical challenge, mainly for the differentiation between mass forming chronic pancreatitis, autoimmune pancreatitis and pancreatic adenocarcinoma. Endoscopic ultrasound (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) can all provide valuable and complementary information in this setting. Among them, EUS has the unique ability to obtain specimens for histopathological diagnosis and can therefore play a crucial role in the evaluation patients with inconclusive findings on initial examinations. Nowadays, new developed techniques associated to EUS, like elastography and contrast enhancement, have shown promising results for the differential diagnosis of these pancreatic lesions(AU)

Últimos avances sobre los tumores pancreáticos / Latest advances in pancreatic tumors

El cáncer de páncreas (CP) continúa siendo una entidad de pésimo pronóstico. Estudios epidemiológicos sugieren que las estatinas en los fumadores podrían constituir un factor protector mientras que la positividad del HbsAg del virus de la hepatitis B podría ser un factor de riesgo. La ultrasonografía endoscópica (USE) continúa siendo el pilar fundamental diagnóstico y surgen avances asociados a ella, como el empleo de la elastografía cuantitativa, los contrastes intravenosos y, más recientemente, la endomicroscopia láser confocal. Surgen nuevos marcadores en orina y en jugo pancreático para la diferenciación del CP con la pancreatitis crónica. Se refuerza claramente el papel del patólogo “en la sala” para aumentar el rendimiento diagnóstico de las punciones guiadas por ecoendoscopia y aparecen estudios multicéntricos comparativos entre agujas de citología y de histología o procore. En relación con los tumores quísticos, los trabajos se centran en validar las nuevas guías de 2012 y en determinar los factores predictivos de malignidad de las lesiones quísticas, fundamentalmente del tumor mucinoso papilar intraductal. Desde el punto de vista terapéutico, la ablación con radiofrecuencia guiada por ecoendoscopia emerge como una técnica factible y segura en tumores solidos y quísticos en determinadas circunstancias (AU)

Pancreatic cancer (PC) continues to have a very poor prognosis. New epidemiological trials suggest that statins could play a protective role in smokers, while HbsAg-positive hepatitis B virus could be a risk factor. Endoscopic ultrasound (EUS) is the main diagnostic tool for PC, and new technologies associated with this technique have emerged, such as quantitative elastography, intravenous contrasts or, more recently, LASER confocal endomicroscopy. New markers in urine or pancreatic juice have appeared to distinguish between PC and chronic pancreatitis. The role of the “on site” cytopathologist to increase the diagnostic yield of EUS-guided pancreatic sampling is completely supported by new prospective trials and some multicenter studies have been reported that compare the standard cytologic needles with the new procore-histology needles. Regarding cystic pancreatic tumors, most studies have aimed to validate the 2012 Sendai international guidelines and to ascertain predictive factors of malignancy in cystic lesions, mainly intraductal papillary mucinous neoplasm (IPMN). The role of intracystic CEA levels in determining malignancy is challenged. From a therapeutic point of view, EUS-guided radiofrequency ablation of cystic and solid lesions has emerged as a feasible and safe procedure in specific circumstances (AU)

Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 2 (tratamiento) / No disponible

La pancreatitis crónica (PC) es una enfermedad compleja, con un amplio espectro de manifestaciones clínicas, que abarca desde pacientes asintomáticos a pacientes con síntomas inhabilitantes o con complicaciones serias. El manejo de la PC frecuentemente difiere entre áreas geográficas e incluso entre centros. Ello se debe a la escasez de estudios de calidad y guías de práctica clínica que aborden el diagnóstico y tratamiento de esta enfermedad. El objetivo del Club Español Pancreático fue elaborar recomendaciones basadas en la evidencia para el manejo de la PC. Dos coordinadores eligieron un panel multidisciplinario de 24 expertos en esta enfermedad. Estos expertos se seleccionaron por su experiencia clínica e investigadora en PC. Se elaboró una lista de preguntas, cada una de las cuales se revisó por 2 panelistas. Con ello se produjo un borrador que se discutió en una reunión presencial por todos los participantes. Los niveles de evidencia se basaron en la clasificación del Oxford Centre for Evidence-Based Medicine. En la segunda parte del consenso se dieron recomendaciones para el manejo del dolor, seudoquistes, estenosis biliar y duodenal, fístula pancreática y ascitis, hipertensión portal izquierda, diabetes mellitus, insuficiencia pancreática exocrina y soporte nutricional en PC (AU)

Chronic pancreatitis (CP) is a complex disease with a wide spectrum of clinical manifestations ranging from asymptomatic disease to disabling forms or serious complications. The management of CP frequently differs among geographical areas and even among centers. These differences are due to the scarcity of high-quality studies and clinical practice guidelines that focus on the diagnosis and treatment of this disease. The aim of the Spanish Pancreatic Club was to create evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts in this disease. These experts were selected on the basis of their clinical and research experience in CP. A list of questions was drawn up and each question was then reviewed by two panelists. These questions were then used to produce a draft, which was discussed in a face-to-face meeting with all the participants. Levels of evidence were based on the classification of the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus process, recommendations were established for the management of pain, pseudocysts, biliary and duodenal stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP (AU)

Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 1 (diagnóstico) / Recommendations of the Spanish pancreatic club on the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis)

La pancreatitis crónica (PC) es una enfermedad relativamente infrecuente, compleja y muy heterogénea. La ausencia de un patrón oro aplicable a las fases iniciales de la PC hace que su diagnóstico precoz sea difícil. Algunas de sus complicaciones, en particular el dolor crónico, pueden ser difíciles de manejar. Hay mucha variedad en el diagnóstico y tratamiento de la PC y de sus complicaciones entre los diferentes centros y profesionales. El Club Español Pancreático ha desarrollado un consenso sobre el manejo de la PC. Dos coordinadores eligieron un panel multidisciplinario de 24 expertos en esta enfermedad. Se elaboró una lista de preguntas. Cada pregunta fue revisada por 2 expertos. Con ello se elaboró un borrador compartido con todo el panel de expertos y discutido en una reunión presencial. En la primera parte del consenso se aborda el diagnóstico de la PC y de sus complicaciones (AU)

Chronic pancreatitis (CP) is a relatively uncommon, complex and highly heterogeneous disease. There is no clear pattern applicable to the initial stages of CP, which hampers its early diagnosis. Some of the complications of CP, especially chronic pain, can be difficult to manage. There is wide variation in the diagnosis and treatment of CP and its complications among centers and health professionals. The Spanish Pancreatic Club has developed a consensus document on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts in this disease. A list of questions was drawn up. Each question was reviewed by two experts. These questions were then used to produce a draft, which was discussed in a face-to-face meeting with all the participants. The first part of the consensus document focusses on the diagnosis of CP and its complications (AU)

Últimos avances sobre los tumores pancreáticos / The latest advances in pancreatic tumors

El cáncer de páncreas (CP) continúa siendo una entidad de pésimo pronóstico. Aparecen estudios epidemiológicos que sugieren nuevos factores protectores de la enfermedad, como el consumo de aspirina y ácido oleico. La ultrasonografía endoscópica (USE) continúa siendo el pilar fundamental diagnóstico, surgiendo avances asociados a ella, como el empleo de la elastografía cuantitativa (coeficiente de elasticidad o strain ratio y el análisis por histograma de colores) y los contrastes por vía intravenosa, así como el desarrollo de nuevas agujas para obtención de material histológico (pro-core), que intervienen en el diagnóstico diferencial. Como novedad para años venideros surge la endomicroscopía confocal para el diagnóstico del CP y de los tumores quísticos, utilizada mediante una sonda a través de la aguja de 19G de ecoendoscopia. En el campo terapéutico aparecen estudios que evalúan la seguridad y la eficacia de la administración intratumoral de gemcitabina mediante USE-punción inyección. En relación con los tumores quísticos, el tumor mucinoso papilar intraductal continúa siendo el más estudiado, apareciendo estudios que evalúan determinados criterios de trasformación maligna y analizan la historia natural de esta neoplasia (AU)

Pancreatic cancer (PC) continues to have a poor prognosis. New epidemiological trials have suggested that there may be protective factors, such as aspirin or oleic acid intake. The main diagnostic tool for PC is endoscopic ultrasound (EUS), and new EUSrelated technologies have appeared, such as quantitative elastography (strain ratio and hue histogram analysis), intravenous contrasts, and the new procore needles to help in the differential diagnosis with other diseases (mainly chronic pancreatitis). In the next few years, intratumoral confocal endomicroscopy will be used for the diagnosis of PC and cystic tumors, by inserting a miniprobe inside the 19G needle of the echoendoscope. Notable therapeutic developments are studies on the safety, feasibility and accuracy of intratumoral gemcitabine administration by EUS-fine needle injection in the treatment of locally advanced PC. In the treatment of cystic tumors of the pancreas, mainly intraductal papillary mucinous neoplasms (IPMN), most studies aim to optimize follow up by assessing predictive factors of malignant transformation and evaluating the natural history of this neop (AU)

Elastografía en la evaluación de la pancreatitis crónica / Elastography in the evaluation of chronic pancreatitis

La ultrasonografía endoscópica (USE) es una herramienta fundamental en el estudio de la enfermedad pancreática, siendo considerada el métodos de elección en la evaluación de la pancreatitis crónica (PC) y del cáncer de páncreas (CP). Sin embargo la USE presenta ciertas limitaciones, sobre todo en la evaluación de pacientes con tumores sólidos (diagnóstico diferencial entre masas inflamatorias y CP), y la variabilidad que existe a la hora de definir los criterios diagnósticos de la PC. La elastografía guiada por USE emerge como una técnica de gran utilidad. Ha mostrado gran rentabilidad en el diagnóstico diferencial de los tumores sólidos, incluida la diferenciación entre el CP y las masas inflamatorias en el contexto de la PC (campo especialmente complejo para todas las pruebas diagnósticas disponibles). También se muestra útil en el diagnóstico de la PC, pudiendo incluso clasificar a los pacientes en función de la severidad de la misma (AU)

Endoscopic ultrasound (EUS) has become an essential tool in the evaluation of pancreatic disease and can be considered the technique of choice for the diagnosis and staging of chronic pancreatitis (CP) and pancreatic cancer (PC). However, EUS has certain limitations, especially in the evaluation of patients with solid pancreatic masses (in the differential diagnosis of CP and PC). Furthermore there is variability in the EUS diagnostic criteria for CP. EUS-guided elastography is emerging as a highly useful tool in this setting. This modality has shown high diagnostic accuracy in the differential diagnosis of solid pancreatic masses, including differentiation between CP and PC. EUS-guided elastography has also been found to be useful in the diagnosis of CP, and can even classify patients according to the severity of their disease (AU)

Qué aporta la ultrasonografía endoscópica en el diagnóstico de los tumores neuroendocrinos de páncreas / Contribution of endoscopic ultrasonograhy to the diagnosis of neuroendocrine pancreatic tumors

Resumen Los tumores neuroendocrinos pancreáticos (TNE) son infrecuentes, presentando una incidencia aproximada de 1/100.000, lo que representa solo un 1–2% de las neoplasias pancreáticas. La localización y estadiaje de los TNE previa a la cirugía es de enorme utilidad, ya que permite optimizar su tratamiento. Sin embargo, su localización es a menudo difícil ya que suelen ser de pequeño tamaño. El aspecto ecográfico más característico de estas lesiones es el de una tumoración redondeada, hipoecogénica, homogénea, con límites precisos y refuerzo periférico en relación a su importante vascularización. La ultrasonografía endoscópica (USE) ha demostrado ser la técnica más precisa para el diagnóstico y localización de los TNE, alcanzando una sensibilidad y especificidad cercanas al 95%, claramente superior a otras técnicas de imagen. La precisión diagnóstica puede incluso incrementarse si se asocia la punción aspiración con aguja fina (AU)

Abstract Neuroendocrine pancreatic tumors (NEPT) are relatively infrequent tumors, with an incidence of approximately 1 case per 100.000 inhabitants, representing only 1–2% of pancreatic neoplasms. Localization and staging of NEPT prior to surgery is essential to allow treatment optimization. However, localizing these tumors is often difficult, mainly because of their small size. On ultrasound, NEPT usually appear as rounded, hypoechoic and homogeneous lesions, with precise limits and peripheral enhancement due to their significant vascularization. The most precise technique for the diagnosis and localization of NEPT is endoscopic ultrasound (EUS), with a sensitivity and specificity as high as 95%, clearly superior to those of other imaging procedures. Overall diagnostic accuracy may even be increased by associating EUS-guided fine-needle aspiration (AU)