Endoscopic ultrasound guided radiofrequency ablation for pancreatic tumors: A critical review focusing on safety, efficacy and controversies

The role of endoscopic ultrasound(EUS)in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreatobiliary disorders.In recent years,its applications for treating pancreatic diseases have broadened,including the implementation of radiofrequency ablation(RFA),which has been traditionally used for treating solid tumors.In this critical indepth review,we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms,adenocarcinoma,and pancreatic cystic lesions.Overall,for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA,with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%.For pancreatic adenocarcinoma,we identified 8 papers with 121 patients.Adverse events occurred in 13%of patients,mostly rated mild.However,no clear survival benefit was demonstrated.For pancreatic cystic lesions,we identified 4 papers with 38 patients.The adverse events were mostly mild and occurred in 9.1%of patients,and complete or partial radiological resolution of the cysts was reported in 36.8%.Notably,the procedure was technically feasible for most of the patients.Nevertheless,a long road remains before this technique finds its definite place in guidelines due to several controversies.EUS-RFA for pancreatic tumors seems to be safe and effective,especially for pancreatic neuroendocrine neoplasms,but multicenter prospective trials are needed to consider this treatment as a gold standard.

Diagnostic approach to faecal incontinence:What test and when to perform?

Faecal incontinence(FI)is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability,morbidity,and increased societal burden.Given the various causes of FI,it is important to assess and identify the underlying pathomechanisms.Several investigatory tools are available including high-resolution anorectal manometry,transrectal ultrasound,magnetic resonance imaging,and electromyography.This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature.Overall,high-resolution anorectal manometry should be the first investigatory tool for FI,followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury,respectively.

Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography:A case-control study

Background:Recurrent common bile duct(CBD)stone is a long-term sequalae among patients who un-derwent endoscopic retrograde cholangiopancreatography(ERCP)with CBD stone extraction.Data regard-ing risk factors for recurrent CBD stone are scarce.We aimed to identify predictors of recurrent CBD stone.Methods:We performed a retrospective case-controlled study from January 2010 to December 2019.In-clusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP,in which complete stone extraction was performed and normal cholangiogram was obtained.Overall,457 patients were included.Forty-two patients(9.2%)had recurrent CBD stone,and 415 patients(90.8%)did not have recurrent CBD stone.Results:In univariate analysis,male sex[odds ratio(OR)=0.49,P=0.033]was a protective factor,while endoscopic stone extraction by basket vs.balloon(OR=2.55,P=0.005),older age(OR=1.03,P=0.003),number of CBD stones(OR=1.99,P=0.037),size of CBD stone(OR=4.06,P=0.003)and mechanical lithotripsy(OR=9.22,P=0.004)were risk factors for recurrent CBD stone.In multivariate logistic regression analysis,mechanical lithotripsy[OR=9.73,95%confidence interval(CI):1.69-55.89,P=0.010],basket clearance vs.combined basket and balloon(OR=18.25,95%CI:1.05-318.35,P=0.046)and older age(OR=1.02,95%CI:1.00-1.05,P=0.023)were risk factors,and male sex(OR=0.39,95%CI:0.19-0.81,P=0.012)was a protective factor.

Predicting common bile duct stones by non-invasive parameters

Background:Common bile duct(CBD)stone affect about 10%of patients with symptomatic cholelithiasis.The American Society for Gastrointestinal Endoscopy(ASGE)published a strategy in 2010 for managing patients with suspected choledocholithiasis.This study aimed to assess the performance of different clinical parameters in predicting CBD stones.Methods:A total of 344 patients suspected to suffer from CBD stone and referred to endoscopic ultrasound(EUS)were included.Parameters were collected and their prediction power for CBD stones was assessed.Results:One hundred and sixty-seven patients without CBD stone according to EUS(group A)were compared to 177 patients with CBD stones(group B).Several predictive factors for CBD stone were identified on univariate analysis.In multivariate regression analysis,CBD width by US(OR=1.224,95%CI:1.073–1.359;P=0.0026),age(OR=1.023,95%CI:1.011–1.035;P=0.0002)and gamma glutamyl transferase(GGT)level(OR=1.001,95%CI:1.000–1.002;P=0.0018)were significantly correlated with CBD stone,with receiver operator characteristics(ROC)of 0.7259.We generated a diagnostic equation[age(yr)×0.1+CBD width(mm)by US×1+GGT(U/L)×0.005]to predict CBD stone with ROC of 0.7287.Conclusions:We suggest this score as a very strong predictor for CBD stones,and to reduce the strength of total bilirubin and transaminases as predictors.

Endoscopic ultrasound role in pancreatic adenocarcinoma treatment:A review focusing on technical success,safety and efficacy

The impressive technological advances in recent years have rapidly translated into the shift of endoscopic ultrasound(EUS)from diagnostic modality into an interventional and therapeutic tool.Despite the great advance in its diagnosis,the majority of pancreatic adenocarcinoma cases are inoperable when diagnosed,thus demanding alternative optional therapies.EUS has emerged as an easy,minimally invasive modality targeting this carcinoma with different interventions that have been reported recently.In this review we summarize the evolving role of interventional therapeutic EUS in pancreatic adenocarcinoma management.

Concise review on the comparative efficacy of endoscopic ultrasound-guided fine-needle aspiration vs core biopsy in pancreatic masses, upper and lower gastrointestinal submucosal tumors

Endoscopic ultrasound(EUS)-guided fine needle aspiration with or without biopsy(FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration(EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUSFNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples(fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Bedside score predicting retained common bile duct stone in acute biliary pancreatitis

BACKGROUND Retained common bile duct(CBD) stone after an acute episode of biliary pancreatitis is of paramount importance since stone extraction is mandatory.AIM To generate a simple non-invasive score to predict the presence of CBD stone in patients with biliary pancreatitis.METHODS We performed a retrospective study including patients with a diagnosis of biliary pancreatitis. One hundred and fifty-four patients were included. Thirty-three patients(21.5%) were diagnosed with CBD stone by endoscopic ultrasound(US).RESULTS In univariate analysis, age(OR: 1.048, P = 0.0004), aspartate transaminase(OR:1.002, P = 0.0015), alkaline phosphatase(OR: 1.005, P = 0.0005), gamma-glutamyl transferase(OR: 1.003, P = 0.0002) and CBD width by US(OR: 1.187, P = 0.0445)were associated with CBD stone. In multivariate analysis, three parameters were identified to predict CBD stone;age(OR: 1.062, P = 0.0005), gamma-glutamyl transferase level(OR: 1.003, P = 0.0003) and dilated CBD(OR: 3.685, P = 0.027),with area under the curve of 0.8433. We developed a diagnostic score that included the three significant parameters on multivariate analysis, with assignment of weights for each variable according to the co-efficient estimate. A score that ranges from 51.28 to 73.7 has a very high specificity(90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity(82%-100%). By performing internal validation, the negative predictive value of the low score group was 93%.CONCLUSION We recommend incorporating this score as an aid for stratifying patients with acute biliary pancreatitis into low or high probability for the presence of CBD stone.

Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia

BACKGROUND Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex.Some of these symptoms might arise from serious underlying diseases,so the promotion of evidence-based guidelines could potentially better align evaluation and treatment.AIM To determine the value of alarm features as a predictive factor for significant endoscopic findings(SEFs)among hospitalized patients presenting with dyspepsia.METHODS We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients.Patients were divided into two groups,with and without SEFs,and compared to elucidate the ability of the different alarm features to predict SEFs.RESULTS During the study,605 patients fulfilled the inclusion criteria.When the demographics and clinical characteristics of the two groups were compared,tachycardia(P<0.05),normocytic anemia,(P<0.05),leukocytosis(P<0.05),and hypoalbuminemia(P<0.05)documented on admission prior to endoscopy were strong predictors of SEFs.Among the alarm features,upper gastrointestinal bleeding,persistent vomiting,odynophagia[odds ratio(OR)=3.81,P<0.05;OR=1.75,P=0.03;and OR=7.81,P=0.07,respectively]were associated with SEFs.Unexplained weight loss was strongly associated with malignancy as an endoscopic finding(OR=2.05;P<0.05).In addition,long-term use of anti-aggregate medications other than aspirin(P<0.05)was correlated to SEFs.CONCLUSION Novel predictors of SEFs were elucidated in this study.These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia.