Simultaneous occurrence of autoimmune pancreatitis and pancreatic cancer in patients resected for focal pancreatic mass

AIM To assess the occurrence of autoimmune pancreatitis(AIP) in pancreatic resections performed for focal pancreatic enlargement.METHODS We performed a retrospective analysis of medical records of all patients who underwent pancreatic resection for a focal pancreatic enlargement at our tertiary center from January 2000 to July 2013. The indication for surgery was suspicion of a tumor based on clinical presentation, imaging findings and laboratory evaluations. The diagnosis of AIP was based on histology findings. An experienced pathologist specialized in pancreatic disease reviewed all the cases and confirmed the diagnosis in pancreatic resection specimens suggestive of AIP. The histological diagnosis of AIP was set according to the international consensus diagnostic criteria.RESULTS Two hundred ninety-five pancreatic resections were performed in 201 men and 94 women. AIP was diagnosed in 15 patients(5.1%, 12 men and 3 women) based on histology of the resected specimen. Six of them had AIP type 1, nine were diagnosed with AIP type 2. Pancreatic adenocarcinoma(PC) was also present in six patients with AIP(40%), all six were men. Patients with AIP + PC were significantly older(60.5 vs 49 years of age, P = 0.045), more likely to have been recently diagnosed with diabetes(67% vs 11%, P = 0.09), and had experienced greater weight loss(15.5 kg vs 8.5 kg, P = 0.03) than AIP patients without PC. AIP was not diagnosed in any patients prior to surgery; however, the diagnostic algorithm was not fully completed in every case. CONCLUSION The possible co-occurrence of PC and AIP suggests that preoperative diagnosis of AIP does not rule out simultaneous presence of PC.

Epithelial markers of colorectal carcinogenesis in ulcerative colitis and primary sclerosing cholangitis

AIM:To evaluate the expression of epithelial markers of colorectal carcinogenesis in patients with long-term ulcerative colitis(UC) and primary sclerosing cholangitis(PSC) before and after transplantation.METHODS:Eight patients with UC and PSC prior to liver transplantation(PSC-UC),22 patients with UC after liver transplantation for PSC(OLT),9 patients with active ulcerative colitis without PSC(UCA),7 patients withUC in remission(UCR) and 10 controls(N) underwent colonoscopy with multiple biopsies.Specimens were analysed histologically and semi-quantitatively immunohistochemically for p53,Bcl-2 and cyclooxygenase-2(COX-2) markers.Statistical analysis was performed by Kruskal-Wallis and Fisher's exact tests.RESULTS:PSC-UC had a statistically significantly higher expression of p53 in the nondysplastic mucosa as compared to OLT,UCA,UCR and N(P < 0.05).We also found a statistically significant positive correlation between the incidence of PSC and the expression of p53(P < 0.001).UCA had a higher p53 expression as compared to UCR.OLT had a significantly lower expression of p53 as compared with PSC-UC(P < 0.001).Bcl-2 had a significant higher bcl-2 expression as compared with controls.No difference in COX-2 expression between PSC-UC,UCR and UCA was found.UCA had higher COX-2 expression as compared to UCR.We also found a statistically significant positive correlation between the expression of COX-2 and p53.Patients after liver transplantation for PSC had a statistically significantly lower expression of the p53 compared with PSCUC(P < 0.001).PSC-UC had the same inflammatory endoscopic activity as OLT and UCR when evaluated with the Mayo score.CONCLUSION:Our study shows that the nondysplatic mucosa of UC patients with PSC is characterised by a higher expression of the tumour suppressor gene p53,suggesting a higher susceptibility of cancer.This p53 overexpression correlates with the presence of PSC whilst it is not present in patients with UC after liver transplantation for PSC.

Patient and physician perception of natural orifice transluminal endoscopic appendectomy

AIM:To investigate perception of natural orifice transluminal endoscopic surgery(NOTES)as a potential technique for appendectomy.METHODS:One hundred patients undergoing endoscopy and 100 physicians were given a questionnaire describing in detail the techniques of NOTES and laparoscopic appendectomy.They were asked about the reasons for their preference,choice of orifice,and extent of complication risk they were willing to accept.RESULTS:Fifty patients(50%)and only 21 physicians(21%)preferred NOTES(P<0.001).Patients had previously heard of NOTES less frequently(7%vs73%,P<0.001)and had undergone endoscopy more frequently(88%vs 36%,P<0.001)than physicians.Absence of hernia was the most common reason for NOTES preference in physicians(80%vs 44%,P= 0.003),whereas reduced pain was the most common reason in patients(66%vs 52%).Physicians were more likely to refuse NOTES as a novel and unsure technique(P<0.001)and having an increased risk of infection(P<0.001).The preferred access site in both groups was colon followed by stomach,with vagina being rarely preferred.In multivariable modeling,those with high-school education[odds ratio(OR):2.68,95% confidence interval(CI):1.23-5.83]and prior colonoscopy(OR:2.10,95%CI:1.05-4.19)were more likely to prefer NOTES over laparoscopic appendectomy.There was a steep decline in NOTES preference with increased rate of procedural complications.Male patients were more likely to consent to their wives vaginal NOTES appendectomy than male physicians(P=0.02).CONCLUSION:The preference of NOTES for appendectomy was greater in patients than physicians and was related to reduced pain and absence of hernia rather than lack of scarring.

Biliary obstruction following transjugular intrahepatic portosystemic shunt placement in a patient after liver transplantation:A case report

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)is a method used to decrease portal hypertension.Biliary stricture is the rarest of the complications associated with this procedure with only 12 cases previously reported in the literature.None of these cases have documented the resolution of biliary stenosis induced by a stent graft.The only curative solutions reported are liver transplantation or bypassing the stenosis with an artificial biliary tract using advanced endoscopic techniques.CASE SUMMARY This is the first reported case of biliary obstruction secondary to TIPS placement in a transplanted liver.In our patient,a portosystemic shunt was created to treat severe veno-occlusive liver graft disease manifesting itself primarily by fluid retention.A cholestatic liver lesion and cholangitis with abscesses developed due to a stent graft-induced stricture in the dorsal segment of the right hepatic duct and the stricture diminished following percutaneous drainage.Endoscopic drainage was performed after unsuccessful removal of the percutaneous catheter resulting in a bilio-cutaneous fistula.Although the liver graft now functions well,the stricture remains refractory even after 44 mo of treatment.CONCLUSION Biliary strictures caused by TIPS in both transplanted and native livers seem refractory to endoscopic treatment.

Endoscopic radiofrequency ablation for malignant biliary obstruction

Cholangiocarcinoma and pancreatic cancer are the most common causes of malignant biliary obstruction.The majority of patients are diagnosed at a late stage when surgical resection is rarely possible.In these cases,palliative chemotherapy and radiotherapy provide only limited benefit and are associated with poor survival.Radiofrequency ablation(RFA)is a procedure for locoregional control of tumours,whereby a high-frequency alternating current turned into thermal energy causes coagulative necrosis of the tissue surrounding the catheter.The subsequent release of debris and tumour antigens by necrotic cells can stimulate local and systemic immunity.The development of endoluminal RFA catheters has led to the emergence of endoscopically delivered RFA,a treatment mainly used for malignant biliary strictures to prolong survival and/or stent patency.Other indications include recanalisation of occluded biliary stents and treatment of intraductal ampullary adenoma or benign biliary strictures.This article presents a comprehensive review of endobiliary RFA,mainly focusing on its use in patients with malignant biliary obstruction.The available data suggest that biliary RFA may be a promising modality,having positive impacts on survival and stent patency and boasting a reasonable safety profile.However,further studies with better characterised and stratified patient populations are needed before the method becomes accepted within routine clinical practice.