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BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) by cautery-enhanced lumen-apposing metal stents (LAMS) has largely been limited to collections located < 10 mm from the luminal wall. We present outcomes of the use of a novel 15-mm-long cautery-enhanced LAMS for drainage of PFCs located ≥ 10 mm away.Methods: This international, multicenter study analyzed all adults with PFCs located ≥ 10 mm from the luminal wall who were treated by EUS-guided drainage using the 15-mm-long cautery-enhanced LAMS. The primary outcome was technical success. Secondary outcomes included clinical success (decrease in PFC size by ≥ 50 % at 30 days and resolution of clinical symptoms without surgical intervention), complications, and recurrence.Results: 35 patients (median age 57 years; interquartile range [IQR] 47-64 years; 49 % male) underwent novel LAMS placement for drainage of PFCs (26 walled-off necrosis, 9 pseudocysts), measuring 85 mm (IQR 64-117) maximal diameter and located 11.8 mm (IQR 10-12.3; range 10-14) from the gastric/duodenal wall. Technical and clinical success were high (both 97 %), with recurrence in one patient (3 %) at a median follow-up of 123 days (58-236). Three complications occurred (9 %; one mild, two moderate).Conclusions: The 15-mm-long cautery-enhanced LAMS was feasible and safe for drainage of PFCs located 10-14 mm from the luminal wall. [ABSTRACT FROM AUTHOR]

This article, published in the journal Endoscopy, examines the diagnostic efficacy of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for suspected pancreatic ductal adenocarcinoma (PDAC). The study analyzed a cohort of 109 patients who underwent EUS-TA tests, with 81.6% of cases confirmed as PDAC after the initial attempt. The remaining 18.3% of patients had inconclusive results on the first attempt, but a second attempt using fine-needle biopsy (FNB) was 100% diagnostic. The study concludes that a negative EUS-TA result on the first attempt does not exclude malignancy, and recommends a second attempt with FNB needles to improve diagnostic yield. [Extracted from the article]

This article presents the findings of an international multicenter study that aimed to investigate the prevalence and characteristics of cystic pancreatic lesions visualized through endoscopic ultrasound in the Gulf Council Countries (GCC). The study included 128 patients from 7 tertiary care centers in Saudi Arabia, the United Arab Emirates, and Kuwait. The most common cystic lesions identified were mucinous pancreatic cysts, which were more common in females. The study highlights the need for further regional epidemiological studies to enhance understanding and develop targeted screening and management strategies for individuals with cystic pancreatic lesions in the region. [Extracted from the article]

This article, titled "An unusual case of pancreatic cyst," discusses the case of a 64-year-old man with a history of cirrhosis. The patient underwent abdominal ultrasound and CT scans, which revealed cholelithiasis, two large pancreatic cysts, and thickening of the colon wall with multiple mesenteric lymph nodes. Further investigations, including a colonoscopy and biopsies, confirmed the presence of signet-ring cell colon carcinoma. The patient underwent laparoscopic cholecystectomy, segmental colon resection, and removal of multiple mesenteric lymph nodes, followed by adjuvant chemotherapy. A pEUS with FNA and Micro-forceps was performed to study the pancreatic cysts, and histopathology confirmed the presence of mucus with signet-ring adenocarcinoma cells in the body cyst and amorphous and biliary material with numerous histiocytes in the tail cyst. The diagnosis of pancreatic tail pseudocyst and a rare case of pancreatic body metastasis of signet-ring cell colon carcinoma was established. [Extracted from the article]

Background: Pancreatic cystic lesions (PCLs) are increasingly found on cross-sectional imaging, with the majority having a low risk for malignancy. The added value of fine-needle aspiration (FNA) in risk stratification remains unclear. We evaluated the impact of three FNA needles on diagnostic accuracy, clinical management, and the ability to accrue fluid for tumor markers.Methods: A multicenter prospective trial randomized 250 patients with PCLs ≥ 13 mm 2:1:1 to 19G Flex, 19G, and 22G needles with crossover for repeated FNA procedures. Diagnostic accuracy was established at 2-year follow-up, with the final diagnosis from surgical histopathology or consensus diagnosis by experts based sequentially on clinical presentation, imaging, and aspirate analysis in blinded review.Results: Enrolled patients (36 % symptomatic) had PCLs in the head (44 %), body (28 %), and tail (26 %). Percentage of cyst volume aspirated was 78 % (72 % - 84 %) for 19G Flex, 74 % (64 % - 84 %) for 22G, and 73 % (63 % - 83 %) for 19G (P = 0.84). Successful FNA was significantly higher for 19G Flex (89 % [82 % - 94 %]) and 22G (82 % [70 % - 90 %]) compared with 19G (75 % [63 % - 85 %]) (P = 0.02). Repeated FNA was required more frequently in head/uncinate lesions than in body and tail (P < 0.01). Diagnostic accuracy of the cyst aspirate was 84 % (73 % - 91 %) against histopathology at 2-year follow-up (n = 79), and 77 % (70 % - 83 %) against consensus diagnosis among nonsurgical cases (n = 171). Related serious adverse events occurred in 1.2 % (0.2 % - 3.5 %) of patients.Conclusions: Our study results demonstrate a statistically significant difference among the three needles in the overall success rate for aspiration, but not in the percentage of cyst volume aspirated. Flexible needles may be particularly valuable in sampling cystic PCLs in the pancreatic head/uncinate process. [ABSTRACT FROM AUTHOR]

Background: Depression is a common mental health disorder, the symptoms of which can disrupt functioning and lead to reduced participation in everyday activities.  Occupational therapy is routinely provided for people with such difficulties; however, the evidence underpinning this intervention for depression has yet to be systematically assessed.Method: A systematic review of the effectiveness of occupational therapy for people with a diagnosis of depression, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was undertaken. Seven databases were searched using terms for depression combined with terms associated with occupational therapy. Due to heterogeneity in study design and outcome measures, a best evidence synthesis was undertaken as an alternative to meta-analysis.Results: Of 1962 articles identified, 63 full texts were assessed and six met the inclusion criteria. Studies were carried out in Canada, Germany, the Netherlands, Taiwan and the United Kingdom. There was strong evidence for the effectiveness of occupational therapy return-to-work interventions for improving depression symptomology, limited evidence for occupational therapy lifestyle interventions for reducing anxiety and suicidal ideation, and limited evidence for improving work participation.  No studies evaluated individualised client-centred occupational therapy, highlighting a gap in research.Limitations: Incomplete reporting within studies and heterogeneity prevented meta-analysis.  English language restrictions were applied.Conclusions: Whilst overall the evidence base for occupational therapy for depression is limited, strong evidence was found for the effectiveness of occupational therapy return-to-work interventions, which is important given the costs associated with mental ill-health and work absence. Further research is needed to strengthen the evidence base. [ABSTRACT FROM AUTHOR]

This article discusses the use of next-generation sequencing (NGS) as a tool for diagnosing genomic abnormalities in pancreatic cyst fluid. The study aimed to evaluate the feasibility and performance of NGS on pancreatic cyst fluid in a real-life setting. The researchers validated the DNA extraction technique and tested a panel of 91 genes by comparing the genomic abnormalities in the cyst fluid with those in histological samples. They then performed DNA extraction and NGS on pancreatic cyst fluids collected through endoscopic ultrasound (EUS). The results showed that NGS was concordant for 90% of the patients, and genomic abnormalities were detected in 20 out of 54 patients. The study concludes that NGS of pancreatic cystic fluid sampled by EUS is possible and effective, although genetic abnormalities were not detected in some patients. [Extracted from the article]

This article discusses a new device that has been developed to improve the assessment of pancreatic cystic lesions (PCLs) during endoscopic ultrasound (EUS). The device, called a through-the-needle loop, was tested in an animal randomized controlled trial using artificial cysts. The results showed that the device was safe and had a higher cell yield compared to the standard procedure. The authors suggest that further clinical studies are needed to validate these findings. [Extracted from the article]

Background: Pancreatic cystic lesions represent a diagnostic dilemma as some may harbor malignancy or have potential for malignant transformation. The aim of this study was to present our experience with a novel endoscopic ultrasound (EUS)-guided microbiopsy procedure enabling procurement of tissue from the wall of the cystic lesion.Methods: We collected data from 31 consecutive patients with pancreatic cystic lesions who underwent an EUS-guided microbiopsy procedure at our institution. Records were retrospectively reviewed from a prospectively maintained database.Results: The technical success was 87.1 %. Diagnostic yield of microbiopsies was 71.0 %. Microbiopsies offered sufficient tissue for morphological and immunohistochemical characterization of the lesions, as well as determination of grade of dysplasia. Furthermore, evaluation of microbiopsies changed the clinical management in six patients (19.4 %). Three nonsevere adverse events were observed (9.7 %): two cases of mild infection and one case of mild pancreatitis. All three patients recovered completely.Conclusions: EUS-guided microbiopsy procedure was technically feasible, with a high diagnostic yield. Further prospective studies are needed to confirm these promising results. [ABSTRACT FROM AUTHOR]

Background: Volumetric laser endomicroscopy (VLE) provides circumferential images 3 mm into the biliary and pancreatic ducts. We aimed to correlate VLE images with the normal and abnormal microstructure of these ducts.Methods: Samples from patients undergoing hepatic or pancreatic resection were evaluated. VLE images were collected using a low-profile VLE catheter inserted manually into the biliary and pancreatic ducts ex vivo. Histological correlation was assessed by two unblinded investigators.Results: 25 patients (20 liver and 5 pancreatic samples) and 111 images were analyzed. VLE revealed three histological layers: epithelium, connective tissue, and parenchyma. It identified distinctive patterns for primary sclerosing cholangitis (PSC), pancreatic cysts, neuroendocrine tumor, and adenocarcinoma adjacent to the pancreatic duct or ampulla. VLE failed to identify dysplasia in a dominant stricture and inflammatory infiltrates in PSC. Reflectivity measurements of the liver parenchyma diagnosed liver cirrhosis with high sensitivity.Conclusions: VLE can identify histological changes in the biliary and pancreatic ducts allowing real-time diagnosis. Further studies are needed to measure the accuracy of VLE in a larger sample and to validate our findings in vivo. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate whether the placement of a coaxial double-pigtail plastic stent (DPS) within a lumen-apposing metal stent (LAMS) may improve the safety of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs).Methods: This was a retrospective cohort study including patients with PFCs and an indication for transmural drainage. Two strategies (LAMS alone or LAMS plus DPS) were used at the endoscopist's discretion.Results: A total of 41 patients were treated (21 LAMS alone; 20 LAMS plus DPS). The characteristics of the PFCs, and the technical and clinical success rates did not differ between groups. The LAMS alone group had a significantly higher rate of adverse events than the LAMS plus DPS group (42.9 % vs. 10.0 %; P = 0.04). Bleeding was the most frequent adverse event observed.Conclusions: The addition of a coaxial DPS to LAMS was associated with a lower rate of adverse events in EUS-guided drainage of PFCs. [ABSTRACT FROM AUTHOR]

Background and study aims The aim of this study was to investigate the long-term outcomes after endoscopic ultrasound (EUS)-guided pancreatic cyst ablation. Patients and methods In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts; clinically indeterminate cysts that required EUS fine-needle aspiration; and/or cysts that grew during the observation period. Treatment response was classified as complete resolution, partial resolution, or persistent cyst, with < 5 %, 5 % - 25 %, and 25 % of the original cyst volume, respectively. Results The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8 %) had adverse events (1 severe, 4 moderate, and 11 mild). Treatment response was as follows: complete resolution in 114 (72.2 %), partial resolution in 31 (19.6 %), and persistent cysts in 13 (8.2 %). Twelve of the 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50 - 85 months) of the 114 patients with complete resolution, only two patients (1.7 %) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR] 7.12, 95 % confidence interval [CI] 2.72 - 18.67) and cyst size less than 35 mm (OR 2.39, 95 %CI 1.11 - 5.16) predicted complete resolution. Conclusion Among patients with pancreatic cysts in whom complete resolution was achieved after EUS-guided cyst ablation, 98.3 % remained in remission at 6-year follow-up. Unilocular form and small cyst size were predictive of complete resolution. This treatment approach may be an effective and durable alternative to surgery.Trial registered at ClinicalTrials.gov (NCT 00689715). [ABSTRACT FROM AUTHOR]

Imaging modalities such as magnetic resonance imaging (MRI), transabdominal ultrasound, and computed tomography (CT) can also characterize PFCs; however, the presence of the important feature of a solid component or debris within a PFC (i. e. walled-off necrosis [WON]) is better assessed by MRI and ultrasound, than by CT scanning. Resource limitations can also influence stent selection, so altering the results, as a plastic stent is much more cost-effective than a metal stent [5]. The two main types of large caliber metal stent are lumen-apposing metal stents (LAMSs; e. g. Axios, Spaxus) and biflanged metal stents (e. g. Nagi, Plumber, and others). [Extracted from the article]

Although a fully covered metal stent was deployed over another guidewire to catch the double-pigtail plastic stent in the cyst, the hepatic end of the fully covered metal stent was misplaced in the peritoneal cavity again (Fig. Thus, a SpyScope DS II (Boston Scientific, Natick, Massachusetts, USA) was inserted into the cyst, and the double-pigtail plastic stent was grasped by a dedicated forceps (SpyBite; Boston Scientific) under direct visualization but was lost during extraction owing to its weak grasping force. Following additional EUS-guided drainage with an external tube from the duodenal bulb, a standard endoscope was inserted into the peritoneal cavity through the fully covered metal stent, but the double-pigtail plastic stent could not be found (Fig. [Extracted from the article]

The article presents the case study of a 50-year-old man with a history of alcohol-induced chronic pancreatitis complicated by a large pancreatic pseudocysts, on who endoscopic ultrasound (EUS)-guided cystogastrostomy was performed.

Background and Study Aim: Comparison of fundamental B-mode endoscopic ultrasonography (FB-EUS) and contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) in the differential diagnosis of pancreatic cysts according to presence of mural nodules.Patients and Methods: Between April 2007 and April 2012, FB-EUS and CH-EUS data were prospectively collected from 581 consecutive patients with pancreatic cysts, and were retrospectively analyzed from 70 with subsequent cyst resection. Presence and height of mural nodules as detected on FB-EUS and CH-EUS were evaluated, and thence accuracies of both methods for diagnosing mucinous versus nonmucinous and malignant versus benign cysts.Results: On pathological examination 48 cysts were mucinous and 22 were nonmucinous; 30 cysts were malignant (high grade dysplasia or invasive carcinoma) and 40 were benign. If presence of a mural nodule was considered to indicate a mucinous cyst, FB-EUS and CH-EUS accuracies did not differ significantly (respectively: sensitivity 85 % vs. 79 %; specificity 46 % vs. 96 %; accuracy 73 % vs. 84 %, P = 0.057). If presence of mural nodule was considered to indicate malignancy, CH-EUS was significantly more accurate than FB-EUS (respectively: sensitivity 97 % vs. 97 %; specificity 75 % vs. 40 %; accuracy 84 % vs. 64 %, P = 0.0001). For diagnosing malignancy by evaluating mural nodule height, the area under the receiver operating characteristic (AUROC) was 0.84 and 0.93 for FB-EUS and CH-EUS, respectively (P = 0.028). Presence of a mural nodule of height ≥ 4 mm on CH-EUS was a sign of malignancy (false-positive fraction 0.2; true-positive fraction 0.93; odds ratio 56.0).Conclusions: CH-EUS is more accurate than FB-EUS for diagnosing malignant pancreatic cysts. [ABSTRACT FROM AUTHOR]

Background and study aims: Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the "string sign"-a test performed at the time of endoscopic ultrasoundguided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). Patients and methods: Patients undergoing EUSFNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥1cm string formed in cyst fluid and lasted for ≥1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. Results: For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58% (95% confidence interval [CI] 44%-70%), 95% (83%- 99%), 94% (81%-99%), and 60% (46%-72%), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥200 ng/mL) were combined, diagnostic accuracy improved from 74% and 83%, respectively, to 89% (P≤0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96%, with a specificity of 90%. Conclusions: The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts. [ABSTRACT FROM AUTHOR]

The author discusses the study which describes the response of patients on pacreatic cyst ablation (PCA) with ethanol and paclitaxel and its potential use to reduce the size of treated cysts.

Background and study aims: Current diagnostic testing is inadequate to determine the malignant potential of pancreatic cysts, resulting in overcautious patient management. Integrated molecular pathology (IMP) testing combines molecular analysis with first-line test results (cytology, imaging, and fluid chemistry) to assess the malignant potential of pancreatic cysts. This multicenter study aimed to determine the diagnostic accuracy of IMP for pancreatic adenocarcinoma, and the utility of IMP testing under current guideline recommendations for managing pancreatic cysts. Patients and methods: Patients who had undergone previous IMP testing as prescribed by their physician and for whom clinical outcomes were available from retrospective record review were included (n=492). Performance was determined by correlation between clinical outcome and previous IMP diagnosis ("benign"/"statistically indolent" vs. "statistically higher risk [SHR]"/ "aggressive") or an International Consensus Guideline (Sendai 2012) criteria model for "surveillance" vs. "surgery." The Cox proportional hazards model determined hazard ratios for malignancy. Results: Benign and statistically indolent IMP diagnoses had a 97% probability of benign followup for up to 7 years and 8 months from initial IMP testing. SHR and aggressive diagnoses had relative hazard ratios for malignancy of 30.8 and 76.3, respectively (both P<0.0001). Sendai surveillance criteria had a 97% probability of benign follow-up for up to 7 years and 8 months, but for surgical criteria the hazard ratio was only 9.0 (P<0.0001). In patients who met Sendai surgical criteria, benign and statistically indolent IMP diagnoses had a >93% probability of benign followup, with relative hazard ratios for SHR and aggressive IMP diagnoses of 16.1 and 50.2, respectively (both P<0.0001). Conclusion: IMP more accurately determined the malignant potential of pancreatic cysts than a Sendai 2012 guideline management criteria model. IMP may improve patient management by justifying more relaxed observation in patients meeting Sendai surveillance criteria. IMP can more accurately differentiate between the need for surveillance or surgery in patients meeting Sendai surgical criteria. [ABSTRACT FROM AUTHOR]

Background and study aims: Endoscopic ultrasound (EUS)-guided ethanol lavage with paclitaxel injection has been shown to be effective for the treatment of pancreatic cystic neoplasms; however, the evidence for effectiveness is based primarily on cyst resolution on imaging. The aim of this study was to evaluate changes in pancreatic cyst fluid DNA following EUS-guided pancreatic cyst ablation (PCA) with ethanol and paclitaxel. Patients and methods: In a single-center, prospective study, patients with suspected benign pancreatic cysts (15-50mm in diameter; =5 compartments) underwent EUS-PCA with ethanol and paclitaxel followed 3 months later by repeat EUS-FNA, cyst aspiration for repeat DNA analysis, and possible repeat EUS-PCA. Abdominal imaging was repeated 3-4 months and 12 months after the second EUS.Changes in baseline pancreatic cyst fluid DNA, procedural complications, and radiographic changes in cyst volume were evaluated. Results: A total of 22 patients (median age 67 years; 15 women) with cysts in the head or uncinate (n=10), body or neck (n=8), and tail (n=4), measuring a median diameter of 25mm (range 15-43mm), underwent one (n=22) or two (n= 9) EUS-PCA procedures. Baseline cyst DNA included mutations in 11 patients (50 %). Postablation cyst fluid (n=19) showed elimination of all baseline mutations in eight patients, new mutations in three, and no changes in eight without a baseline mutation. The largest per-protocol postablation image-defined volume change (n=20) from either of the follow-up abdominal imaging studies (n=20) demonstrated complete response (<5% original volume) in 10 patients (50 %), partial response (5%-25% original volume) in 5 (25 %), and a persistent cyst (>25% original volume) in 5 (25 %). During a median follow-up of 27 months (range 17-42 months), adverse events from all EUS-PCAs (n=31) included abdominal pain alone in four patients (13 %), pancreatitis in three (10 %), peritonitis in one (3 %), and gastric wall cyst in one (3 %). The adverse events were classified as moderately severe in four patients (three with pancreatitis, one with peritonitis). Conclusion: EUS-PCA with ethanol and paclitaxel may possibly eliminate mutant DNA in neoplastic pancreatic cysts. This technique leads to complete or partial image-defined resolution in 75% of cysts but may lead to rare adverse events. Clinical trial registration: ClinicalTrials.gov (NCT01643460). [ABSTRACT FROM AUTHOR]

Introduction Abdominal enteric duplications are found in 1 out of 4,500 autopsies, and only 4 to 5% of them are located in the duodenum, where they may be connected with the biliary or pancreatic ducts. The aim of this study was to describe the clinical features, management, and outcome of a large series of duodenal duplication cysts. Materials and Methods The charts of all patients treated at our institution between 1985 and 2011 were reviewed retrospectively with particular attention to imaging, surgical technique, pathology, and outcome. Results During that period, 11 cases (81.8% females) were treated. Out of the 11 patients, 8 were symptomatic (vomiting in 3, recurrent acute pancreatitis in 2, and abdominal pain in 3) and 3 were tentatively diagnosed prenatally as choledochal cysts. Median age at surgery was 2.3 years (0 to 13.7) and preoperative diagnosis was correct in five cases. Five cysts were developed intraluminally and three communicated with the biliary duct (one), pancreatic duct (one), or both (one). Surgical treatment consisted of complete resection (four cases, including one pancreaticoduodenectomy), partial removal including all mucosa (four cases), and internal marsupialization (three cases). In all cases, the ductal communications were divided and opened into the duodenal lumen. In six cases, ectopic gastric mucosa was found. All patients recovered uneventfully. Conclusion Duodenal duplication cysts are rare and may have bizarre anatomical patterns due to biliopancreatic involvement. Optimal treatment is complete surgical removal, and, if this is not possible, partial removal including the mucosa or marsupialization are also good alternatives. In cases with biliary and pancreatic tract connections, these have to be taken down carefully and drained into the duodenum. [ABSTRACT FROM AUTHOR]

Background and study aims: It is uncertain if needle gauge impacts the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic mass lesions. Our aim was to use meta-analysis to more robustly define the diagnostic accuracy of EUS-FNA for pancreatic masses using 22G and 25G needles. Patients and methods: Studies were identified by searching nine medical databases for reports published between 1994 and 2011, using a reproducible search strategy comprised of relevant terms. Only studies comparing the overall diagnostic accuracy of 22G vs. 25G EUS needles that used surgical histology or at least 6 months clinical follow up for a gold standardwere included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. When required, the original investigators were contacted to provide additional data. Pooling was conducted by both fixed-effects and randomeffects models. Diagnostic characteristics (sensitivity, specificity, positive and negative likelihood ratios) with 95% confidence intervals (CIs) were calculated. Results: Eight studies involving 1292 subjects met the defined inclusion criteria. Of the 1292 patients, 799 were in the 22G group and 565 were in the 25G group (both needles were used in 72 patients). The pooled sensitivity and specificity of the 22G needle were 0.85 (95 %CI 0.82-0.88) and 1 (95 %CI 0.98-1) respectively. The pooled sensitivity and specificity of the 25G needle were 0.93 (95 %CI 0.91-0.96) and 0.97 (95 %CI 0.93-0.99) respectively. The bivariate generalized linear random-effect model indicated that the 25G needle is associated with a higher sensitivity (P=0.0003) but comparable specificity (P= 0.97) to the 22G needle. Conclusions: This meta-analysis suggests 25G needle systems are more sensitive than 22G needles for diagnosing pancreatic malignancy. [ABSTRACT FROM AUTHOR]

Pancreatic fluid collections include a wide range of entities such as cystic neoplasms, both benign and malignant; vascular pathology such as pseudoaneurysms and hematomas; and a host of other entities such as pseudocysts, seromas, abscesses, and bilomas. The distinction between these entities requires correlating an often complex and overlapping clinical presentation with findings on imaging studies, typically computed tomography, magnetic resonance imaging, and ultrasound. As complex as the diagnostic work-up may be, the treatment of pancreatic collections poses its own set of challenges and often requires a multidisciplinary collaboration among interventional radiologists, surgeons, and gastro-enterologists. The best treatment algorithm is determined by careful review of radiologic imaging studies combined with endoscopic retrograde cholangiopancreatography to apply therapies such as surgical resection; drainage or debridement; endoscopic ultrasound-guided drainage; aspiration or biopsy; and imaging-guided percutaneous drainage, aspiration, or biopsy. This article focuses on the diagnosis and multidisciplinary management of pancreatic fluid collections such as abscesses, pseudocysts, and necrosis. [ABSTRACT FROM AUTHOR]

Background and study aim: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for cyst fluid analysis (CFA) is often requested for pancreatic cystic lesions, to determine whether to operate or to observe. If this decision is not influenced by the EUS findings, the procedure may be unjustifiable. We aimed to determine whether EUS-CFA results predict surgery or observation in patients with pancreatic cysts referred for EUS. Patients and methods: Consecutive patients referred to a quaternary pancreaticobiliary center for EUS evaluation of pancreatic cysts were eligible. Clinical data, computed tomography (CT) results, EUS findings, and CFA results were reviewed retrospectively. Statistical analysis was performed to determine variables associated with surgery versus observation. Results: Over 33 months, data on 194 consecutive patients referred for EUS for evaluation of pancreatic cysts were analyzed. Of these, 136 (70 %) patients had EUS-FNA. After the initial workup (including EUS with/without CFA), 35 (18 %) underwent surgery. Predictors of surgery were: younger age (< 65 years) (P = 0.0027), malignant appearance at EUS (P = 0.02), and history of EUS-FNA (P = 0.012). Cyst fluid appearance, and carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), and amylase levels were not significant determinants of surgery. In 14/50 (28 %) of cases where EUS-CFA clearly suggested benign serous lesions, surgery was still performed and in 9/11 (82 %) of cases with malignant EUS-CFA findings, surgery was not done. Conclusions: In patients with pancreatic cysts referred for EUS, age and EUS appearance independently predict surgery. The "perceived need for EUS-CFA" also predicts surgery, but not the EUS-CFA results. The clinical value of EUS-CFA requires further study. [ABSTRACT FROM AUTHOR]

Background and study aims: Endosonography is considered a valuable technique in the evaluation of pancreatic cysts. The aim of the present study is to assess interobserver agreement, in three different observer groups, regarding EUS for characterization of pancreatic cysts. Patients and methods: Video sequences of 40 EUS procedures for pancreatic cysts were prepared. Three groups of observers had different levels of EUS experience: group 1 comprised four experts with extensive EUS experience, group 2 had four "semi-experts" with limited EUS experience, and group 3 (novices) comprised four nonexpert resident physicians without EUS experience. Features scored included septations, nodules, solid components, and pancreatic duct communication. A presumptive diagnosis had to be specified. The intraclass correlation coefficient (ICC) was used, with agreement classed as excellent (> 0.80), good (0.61-0.80), moderate (0.41- 0.60), fair (0.20-0.40), and poor (< 0.20). Results: Agreement regarding nodules was good among experts (ICC 0.65) and fair in the semi-expert and novice groups (ICC 0.32 and 0.37, respectively). For presence of solid components there was significantly higher agreement among experts (ICC 0.52) compared with the other two groups (semi-experts 0.09, and novices 0.03). Agreement regarding specific diagnosis was moderate in the expert group (0.43), poor among the semi-experts (0.09), and fair among the novices (0.30). Conclusions: Interobserver agreement among expert endosonographers was mostly moderate for characteristics of pancreatic cysts. However, interobserver agreement for experts was equal to or higher than that in the semi-expert and in the novice groups. [ABSTRACT FROM AUTHOR]

The article discusses various studies related to endoscopic ultrasonography (EUS). These studies include the endosonographic characteristics of mediastinal lymph nodes which gives prognosis in patients with lung cancer, the clinical management of pancreatic cysts that resolves following an EUS-guided ethanol ablation, and the endoscopic staining of pancreatic lesion which leads to time-efficiency during laparoscopic distal pancreatectomy. An overview of pancreatic function tests is provided.

The article presents a case study of a 38-year-old woman who undergone endoscopic ultrasound (EUS)-guided drainage to treat her pancreatic pseudocyst using double-pigtail plastic stent but an emergency exploration was made to retrieve the stent that has migrated inside the collection.

BACKGROUND AND STUDY AIMS: Generally, cystic tumors are divided into two categories: neoplastic cystic tumors and non-neoplastic cystic (NNC) tumors. Neoplastic cystic tumors include mucinous cystic neoplasm (MCN), intraductal papillary-mucinous neoplasm (IPMN), and serous cystic neoplasm (SCN). MCNs and IPMNs have the potential to progress to a malignant state, whereas SCNs are known for their almost benign behavior. Thus, in order to make management decisions, it is important to distinguish between potentially malignant (MCN and IPMN), and benign (SCN and NNC) tumors. The aim of this study was to retrospectively investigate the value of endoscopic ultrasonography (EUS) for the differential diagnosis of cystic tumors of the pancreas. PATIENTS AND METHODS: A total of 76 patients with cystic tumors of the pancreas were preoperatively examined by EUS. Eight cases were MCNs, 45 were IPMNs, 13 were SCNs, and 10 were NNC tumors. The EUS findings relevant to distinguishing between potentially malignant and benign were analyzed statistically. RESULTS: All patients with MCNs were female and all these tumors were located in the pancreatic body/tail. IPMN, however, occurred predominantly in men, and in the pancreatic head. Eight of 11 monolocular cystic tumors were NNC in nature. Eleven of 13 SCNs included microcystic areas within the tumors. All MCNs were round in appearance, whereas 93?% of IPMNs were not round in appearance. Mural nodules were present in 25?% of MCN and 38?% of IPMN cases. In univariate analysis, age, tumor size, locularity, the number of cystic formation, cystic component, and appearance were significant variables. In multivariate analysis, locularity and cystic component were important for differential diagnosis of potentially malignant cystic tumors. CONCLUSIONS: The characteristics of cystic tumors of the pancreas revealed by EUS are useful for their differential diagnosis. [ABSTRACT FROM AUTHOR]

During dissection, the tumor was tightly attached to the proper muscle layer; therefore, a clip attached with dental floss was deployed to secure the dissection plane between the tumor and muscle layer (Fig. Histopathologically, the cystic lesion was lined with columnar epithelial mucosa and had its own muscle layer, and ectopic pancreatic tissue of acinar structure was present in the cystic wall (Fig. 3 A clip attached with dental floss was deployed to secure the dissection plane between the tumor and the muscle layer. [Extracted from the article]

An introduction is presented in which the editor discusses various reports within the issue on topics including contrast harmonic endoscopic ultrasonography and pancreatic cystic lesions.

Needle-based confocal laser endomicroscopy of pancreatic cystic lesions: a prospective multicenter validation study in patients with definite diagnosis. In regard to the use of novel endoscopic techniques requiring a 19G needle, the addition of EUS-guided needle-based confocal endomicroscopy (nCLE) and EUS-guided through-the-needle microbiopsy forceps (TTNB) has revealed a higher risk of acute pancreatitis. [Extracted from the article]

Even if only a partial response was shown in 62 % of patients without complete response, their symptoms still improved after ablation. The authors declare that they have no conflict of interest. letter We thank Dr. Lorenzo and colleagues for their interest in our study, which involved the follow up of 379 patients with serous cystic neoplasms (SCNs) [1]. Among these 60 patients, those with an uncertain diagnosis underwent surgery, and only symptomatic patients with pathologically confirmed SCNs (5.3 %) underwent endoscopic treatment. [Extracted from the article]

The article offers information on the clinical presentation and surgical management of gastric duplication cysts in the pancreas. Topics include the etiology of alimentary canal duplications, the use of antenatal ultrasound imaging in detection, and the occurrence of chronic pancreatitis with enteric duplication cysts.

We report a case of two abdominal cystic formations in an 18-month-old girl. Laparotomy was performed with surgical removal of both cysts. The cysts were connected by a fibrous bridge. Histology revealed a gastric duplication cyst and a ductal pancreatic cyst originating from an aberrant pancreatic lobe. No fistula was found either to the alimentary tract or in either of the cysts. The clinical picture and treatment are described and compared to findings in the literature. [ABSTRACT FROM AUTHOR]

However, they also report a significant risk of postoperative adverse events in 10 % of patients, including acute pancreatitis (n = 9) and significant intracystic hemorrhage (n = 1). In our experience using the 19 G for endoscopic ultrasound-guided needle-based confocal endomicroscopy, there were no events of post-procedural acute pancreatitis among those with serous cystadenomas [4]. [Extracted from the article]

The article discusses the finding of an incidental pancreatic cystic lesion when surveillance magnetic resonance imaging (MRI) was done for a known left renal lesion in an old man of age 60 years.

The article discusses the finding of an abdominal ultrasound performed to diagnose Adenocarcinoma in a 71-year old patient following the drainage of a pancreatic cyst.

The article presents the case study of a 46-year-old woman presenting with a large walled-off collection possibly related to an earlier episode of pancreatitis. Computed tomography (CT) scanning revealed the need for immediate retrieval of a maldeployed lumen-apposing metal stent (LAMS) and salvaging of the original cystogastrostomy. The importance of using multimodal imaging such as white-light endoscopy, endoscopic ultrasound (EUS) and fluoroscopy in the process is mentioned.

The article presents a case study of a 43-year-old patient, who underwent Whipple operation having Roux-en-Y hepaticojejunostomy for a pancreatic cyst, presented with cholangitis and choledocholithiasis.

A case study is presented of a 64-year-old woman with newly diagnosed type 2 diabetes mellitus who was admitted with intermittent abdominal pain and mentions that multifocal pancreatic cystic lesions was diagnosed with a dilated main pancreatic duct and calcification of a cyst wall.

The article presents a case study of a 68-year-old man who went through endoscopic ultrasound (EUS) of a cystic lesion in the pancreatic neck.

The article presents a case study of a 49-year old woman who was incidentally discovered to have cystic pancreatic neck lesion without apparent communication with the Wirsung duct. Histological examination showed a fibrous wall lined by epithelial cells, consistent with the diagnosis of a mucinous non-neoplastic cyst.

The article presents a case study of an 85-year-old woman with an incidental solitary pancreatic cystic lesions (PCLs). The patient underwent into computed tomography (CT) scan and biosies and revealed few mucinous cells in the cyst fluid. The article also discusses endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA), resection of intracystic nodule, and carcinoembryonic antigen.

The article describes the case of a patient with gastroduodenal artery (GDA) pseudoaneurysm as a result of a plastic stent following pseudocyst drainage procedure. It discusses the symptoms experienced by the patient, the result of the endoscopic retrograde pancreatography, findings from gastroscopy, and characteristics of GDA pseudoaneurysm.

The article presents case study of a 70-year-old man who was referred for endoscopic drainage of a pancreatic pseudocyst. It states that the patient had developed acute pancreatitis because of choledocolithiasis, and mentions that Computed tomography (CT) repots of the patient revealed the presence of a cystic lesion in the head of the pancreas. It mentions complications in endoscopic drainage fro pancreatic pseudocyst, such as bleeding, perforation, and infection. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports published within the issue which include the challenges of pancreatic cyst differentiation, the endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE), and methods in cystadenomas diagnosis.

The article presents a case study of a 54-year-old patient with a pancreatic cyst lesion resulting to a massive pneumoperitoneum. The patient was directed to the hospital's emergency unit to underwent endoscopic ultrasound (EUS)-guided transmural drainage. Details on the step-by-step medical procedure to prevent the leakage of fluids to peritoneal cavity is explored. The article also examines the use for endoscopic management therapy for pancreatic fluid collections.

The article presents a case study of a 45-year-old patient has admitted to the hospital for intermittent upper abdominal pain and received a combined flurbiprofen and remifentanil through intravenous infusion for analgesia. The hospital physicians have used for extracorporeal shock wave lithotripsy as treatment for the patient's with a trapped stone basket in the pancreatic duct. Details on the step-by-step medical procedure to remove the pancreatic stone is also discussed.