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A endoscopic ultrasound-guided fine needle aspiration/biopsy (EUS-FNA/B) of pancreatic solid and cystic lesions is a modality, which huge numbers of articles has showed its high diagnostic accuracy. The degree of technical difficulty, size and type of needle, endoscopic technique, use of suction to aspirate tissue, use or not use of a stylet in the needle assembly, maneuvers to have high quality tissue, availability of an on-site cytopathologist, and, finally, end sonographer’s experience and skills who does the procedure have impact on the EUS-FNA results. Standard 19-G and 22-G fine-needle aspiration needles with or without high negative pressure have proven to be reliable in obtaining high-quality histologic samples in various indications. Twenty-five-gauge (25-gauge) needles provide better diagnostic yield when sampling pancreatic lesions compared with 22-G needles. The novel 19-G and 22-G ProCore™ needles have demonstrated a high yield in obtaining histologic samples, whereas 25-G. ProCore™ seems unsuitable for histology. A cytopathology service should be involved early in the planning process for establishing an EUS-FNA service. Data on the newly developed 20-G ProCore™, SharkCore® and Acquire® needles are limited, but appear very promising. Use of the stylet does not increase the yield of endoscopic ultrasonography-fine-needle aspiration and is more cumbersome to use. In perspective, endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is expected to refine differential diagnostic capabilities, favor widespread EUS utilization, and pave the road to targeted therapies and monitoring of treatment response. Approximately 3 to 5 passes should be sufficient to obtain a diagnosis. We need further studies for assessment of the use of Suction, Capillary (“Slow-Pull”), Wet and Fanning techniques.
Pancreatic mass; Endosonography; Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA); Tissue aquisition; Stylet; Diagnostic accuracy; Cytology; Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB).
Chronic non-healing or refractory pancreatic fistulae are rare complications of pancreatic surgery (pancreaticoduodenectomy, distal pancreatectomy) or pancreatitis.
Materials and Methods
We conducted a thorough literature search of electronic databases such as PubMed, Google Scholar, BioMed Central, and Cochrane Library using the keywords and medical subject headings (MeSH) terms “chronic pancreatic fistula”, “post-operative fistula”, “fistula management” and “refractory pancreatic fistula”. The purpose of this review is to evaluate the management options for refractory pancreatic fistula (PF).
Literature reveals that refractory pancreatic fistulae have been managed by techniques like endoscopic ultrasound (EUS)-guided techniques like transmural puncture by clamping, puncture of the fistula tract, transmural placement of pigtail stent, and EUS-guided pancreaticogastrostomy. Other techniques are postoperative endoscopic pancreatic stent placement in Grade C pancreatic fistula, intestinal decompression catheter insertion into the jejunum, embedding fistulojejunostomy, and fistulojejunostomy.
In conclusion, embedding fistulojejunostomy, EUS-guided transmural puncture by clamping, and EUS-guided transmural placement of pigtail stent are effective techniques for the management of refractory pancreatic fistulae. Yet further studies in a larger population are recommended.
Chronic pancreatic fistula; Pancreatectomy; Pancreaticoduodenectomy; Fistutolojejunostomy; Post-operative pancreatic fistula.
Although worrisome features represent an indication to perform endoscopic ultrasound study, recent studies have showed that these conditions are not strictly related to high risk of malignancy. Pancreatic resection for worrisome imaging features often demonstrates pathology consistent with low-grade dysplasia. Worrisome features should be considered as indicators of mostly
low-grade dysplasia. High-risk stigmata are more consistent for diagnosis of malignant lesions.
Worrisome features; High-risk stigmata; Intraductal papillary mucinous neoplasm (IPMN); Pancreatic neoplasm; Pancreatic high-grade dysplasia; Pancreatic low-grade dysplasia.
Isolated pancreatic injury is relatively uncommon due to its mostly retroperitoneal location. However, if present, it is associated with other visceral injuries and causes serious complications if expected management is delayed.
In this report we have discussed about the different minimal invasive management approaches in two cases of pancreatic injury. The first case had American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade IV pancreatic injury with late presentation who underwent ultrasound-guided percutaneous drainage of pseudocyst with video assisted lavage of cavity, followed by endoscopic retrograde cholangiopancreatography (ERCP) guided pancreatic duct stenting. Second case had AAST-OIS grade II pancreatic injury which was managed with serial percutaneous drainage.
Management of pancreatic injury is complex. Evolving trend of minimal invasive techniques of management for selected patients with higher grade pancreatic injury is associated with better outcomes.
Pancreatic injury; Minimal invasive; Serial drainage.
It is now estimated that the number of people living with diabetes worldwide in 2045 will be approximately 783 million, rising much faster than the global population growth of about 20%. In addition to the traditional known host risk factors (life-style changes associated with urbanization, physical inactivity, obesity and aging), it is probably prudent to begin to give serious thought to exposure to environmental toxicants, either because of mere geographical location or because of human industrial activity, as possible significant contributors. This knowledge could raise awareness while prompting us to find new ways to protect people and the environment.
Diabetes; Environmental toxicants; Dioxins; Arsenic; Cadmium.
Constant inflammation and irreversible pancreatic tissue destruction are hallmarks of the disease of chronic pancreatitis (CP), which results in the decrease of both exocrine and endocrine function over time. It is a multifactorial disease, with a wide range of symptoms and geographic variation.
Aim of this study is to study clinical profile and management of CP with respect to demography, clinical findings, lab parameters, imaging investigations and management modalities.
A cross-sectional observational study was conducted which included the patients admitted to the tertiary care center presenting with the clinical diagnosis of CP. The study was conducted over a period of 2-years from November 2019 to October 2021. A total sample size of 71 patients was included.
In the study, it was observed that the majority of patients were in the age group of 51-60-years (47.89%) followed by 41-50-years (21.12%) mean age ranges from 56.54±12.63-years. The majority of patients were male (76.06%) and females were 23.94%. The distribution of patients according to aetiology showed that the majority of patients had aetiology of alcoholism (43.66%) followed by idiopathic (29.57%) Gall/Biliary stones (21.12%) and post-operative (5.63%). Majority of patients presented with pain in the abdomen (85.92%). The distribution of patients according to ultrasound sonography test (USG) findings showed that majority of patients shows pancreatic calcification (54.93%) followed by pancreatic pseudocyst (32.39%) and gall stones (19.72%). The distribution of patients according to computed tomography (CT) findings showed that majority of patients shows pancreatic calcification (70.42%). In the present study, it was observed that majority of patients were managed conservatively (43.66%) followed by cystogastrostomy (18.31%) and cystojejunostomy (8.45%). Endoscopic retrograde cholangiopancreatography (ERCP) was done among 14 (19.72%) patients. Lateral pancreaticojejunostomy was done in 6 (8.45%) patients and pancreaticoduodenectomy (Classical Whipple’s) was done in 4 patients (5.63%). The distribution of patients according to pain relief by various management showed that majority of getting relief from pain by surgery (69.23%) followed by ERCP (35.71%) and the least by conservative/analgesics (6.45%).
Chronic pancreatitis is progressive inflammatory disease. Alcoholic pancreatitis being most common etiology. Pain is most common presenting symptom. CT scan abdomen most useful in confirming diagnosis in our set up. Pseudocyst being common complication seen. Surgery gives relief of pain in most of the cases. The key to a better outcome is making the right decisions in terms of diagnosis, patient selection for surgery, and surgical type.
Chronic pancreatitis; Inflammation; Etiology.
Pancreatic traumatic injuries should be managed by multidisciplinary approach. Standard redo surgery can be avoided or supported by innovative mininvasive approaches both endoscopically and/or radiologically. Pancreatic endotherapy has an increasing role in the management of pancreatic injuries. Understanding the pathophysiology of pancreatic leak is crucial to guide the treatment. Endoscopic treatment must be tailored on the type and site of pancreatic fistula to achieve the optimal clinical outcome: there is not a one-way standard treatment but the best treatment for different types of pancreatic injuries considering both retrograde and endoscopic ultrasound (EUS)-guided approaches.
Pancreatic fistula; Pancreatic traumatic injury; Endoscopic retrograde cholangiopancreatography (ERCP).
letter to the editor
Deputy Physician-in-Chief and Director of Medical Oncology Northwell Health Cancer InstituteProfessor Medical Oncology Zucker School of Medicine Lake Success, NY 11042, USA
Department of Surgery and Translational Medicine Careggi Hospital of Florence Firenze, Italy
Clinical Professor Department of Medicine University of Szeged Szeged, Dugonics tér 13, 6720, Hungary
Department of Gastroenterology Hospital Universitario de León C/ Altos de Nava SN. 24071. León. Spain