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OC.09.5 ASSESSMENT OF THE UTILITY OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN THE EVALUATION OF ACUTE BILIARY PANCREATITIS (ABP): A PROSPECTIVE PILOT STUDY
Abstracts of the 18th National Congress of Digestive Diseases / Digestive and Liver Disease 44S (2012) S55–S220
S76 OC.09.5
ASSESSMENT OF THE UTILITY OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN THE EVALUATION OF ACUTE BILIARY PANCREATITIS (ABP): A PROSPECTIVE PILOT STUDY A. Anderloni ∗ , M. Galeazzi, M. Ballarè, M. Pagliarulo, S. Andorno, M. Del Piano Ospedale “Maggiore della Carità”, Novara, Italy Background and aim: ABP necessitates urgent diagnosis and treatment by endoscopic removal of common bile duct (CBD) stones. In clinical practice the decision to perform early ERCP is often based on biochemical and radiological criteria. EUS is not currently a worldwide standard diagnostic procedure early in the course of ABP, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions and therefore in preventing unnecessary ERCP. Aim: To investigate the clinical impact of early EUS in the management of ABP. Material and methods: From January 2010 to November 2011 all patients presenting to the A&E department with ABP were prospectively included in the study and were categorized into low, moderate, and high probability of CBD stones. Predicted severity of acute pancreatitis was assessed according to APACHE and Glasgow criteria. All the included patients underwent EUS within 48 hours from the admission. ERCP was performed immediately afterward if a biliary stone was identified. The following parameters were investigated: age, sex, fever, dilated CBD, bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (p<0.05) were entered in a multivariate logistic regression model. Results: 41 patients (21 female), mean age 62,3 (SD+16,9) were prospectively included in the study. 12 patients were classified as low probability of CBD stones, 14 as moderate probability and 15 as high probability. CBD stones were identified by EUS in 21 (51,2%) patients (4 with low probability, 7 with moderate probability and 10 with high probability) and confirmed at ERCP. 5 (33%) patients with high probability of CBD stones had a negative EUS. 28 patients had severe pancreatitis; among them 12 (43%) had CBD stones. Table 1 Positive Negative Total
Low
Moderate
High
Total
8 4 12
7 7 14
5 10 15
20 21 41
Conclusions: Our results confirm that commonly used biochemical and radiological predictors of the presence of CBD stones in patients with ABP are unreliable. Early EUS seems to be safe and accurate in identifying CBD stones, and can be used early in the management of ABP to select patients who would benefit from endoscopic treatment and to avoid unnecessary ERCP.
OC.09.6 A REAL-WORLD ANALYSIS OF THE OUTCOME OF PATIENTS WITH IPMN AND INDICATION FOR SURGERY ACCORDING TO INTERNATIONAL ASSOCIATION OF PANCREATOLOGY (IAP) CRITERIA IN WHOM SURGERY IS NOT PERFORMED M. Piciucchi ∗ ,1 , G. Capurso 1 , M. Del Chiaro 2 , M. Antonelli 1 , R. Valente 1 , M. Signoretti 1 , G. Zerboni 1 , G. Leonardi 2 , E. Iannicelli 1 , M. Cavallini 1 , V. Ziparo 1 , U. Boggi 2 , G. Delle Fave 1 1 Ospedale
S.Andrea, Università La Sapienza, Rome, Italy; 2 Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy Background and aim: PMNs are increasingly diagnosed incidentally, in patients with other diseases.The indication for surgery according with IAP criteria, may be difficult to be applied to elderly patients with incidental detection of IPMN, and/or major comorbidities. However, the outcome of
these patients who do not undergo intervention has not been investigated. We aim to assess the outcome of patients with IPMN and IAP criteria for resection, who did not receive surgery. Material and methods: Retrospective analysis of a cohort of IPMN, prospectively enrolled in 2 centers, to assess the different outcome of patients with an indication for surgery and potentially resectable IPMN who did, or did not underwent surgery. Results: According, to IAP guidelines, of 103 patients with IPMN (64 F, age: 70; 38-95), 30 (29,1%) had indication to surgery and resectable IPMN. 17 of these underwent resection (Group 1), whereas in 13 (Group 2) an observational follow up was preferred, due to comorbidities and/or advanced age. Indeed, patients in Group 2 were significantly older (median 77 yrs vs 71), more often had major comorbidities (61,53 vs 29,4%) and an incidental diagnosis (68% vs 41% in Group 1). 82% of Group 1 had an IPMN affecting the main duct as compared to 53.8% in Group 2. However, the final histology confirmed malignancy in only 29% of resected pts. Median survival after the therapeutic decision (surgery vs no surgery) was similar: 23 months in Group 1 vs 19 in group 2 (p=0,61). Survival assessed by Kaplan-Meier curve was not different in two groups (p=0,30). Mortality was 30,76% in Group 2 (4 pts died to disease progression) and 11,76% in Group 1, where 2 pts died due to surgical complications. 2 other pts in Group 1 had disease recurrence in the remnant pancreas during the follow-up. Conclusions: In this series, 43% of patients with IPMN and indication for surgery did not undergo intervention due to advanced age and/or major comorbidities. Although this therapeutic choice is not codified, it seems reasonable and not associated with a worse outcome. Such an option should be carefully discussed with patients, also keeping in mind that the rate of malignancy in this setting is as low as 30%.
OC.10.1 I-SCAN HIGH-DEFINITION WHITE LIGHT ENDOSCOPY AND COLORECTAL POLYPS: PREDICTION OF HISTOLOGY, INTEROBSERVER AND INTRAOBSERVER AGREEMENT F. Pigò ∗ , H. Bertani, M. Manno, V.G. Mirante, A. Caruso, C. Barbera, R. Manta, G. Olivetti, R.L. Conigliaro Nuovo Ospedale Civile Sant’Agostino Estense, Modena, Italy Background and aim: Progress of quality of videocolonoscopy increased recognition of non-neoplastic polyps with resulting added costs for pathological analysis and risks for the patient. I-Scan (Pentax® ,Japan), among virtual chromoendoscopic techniques, is a new tool for diagnosis and differentiation of colonic polyps. This imaging system, combined with high definition white light (HDWL) endoscopes, could increase the accuracy of diagnosis and lead to time/cost savings. The aim of the study was the evaluation of HDWL I-Scan endoscopy for diagnostic prediction of histology, inter- and intraobserver agreement for colorectal polyps. Material and methods: 150 images of polyps were consecutively collected during 78 colonoscopies. Pictures were taken with I-Scan (set-up: surface enhancement 4+ and tone enhancement p-/c-mode) and with HDWL colonoscopes. Four skilled endoscopists, not involved in the collection of cases, predicted the polyps’ histology (neoplastic vs non-neoplastic) and repeated the assessment after 6 months. Histology prediction was based on the evaluation of mucosal surface and vascular pattern. The inter- and intraobserver agreement were calculated by using the values of Kappa (Landis & Koch 1977): slight =0.2; fair 0.21-0.4; moderate 0.41-0.6; substantial 0.61-0.80 and almost perfect 0.81-1.00. Results: Characteristics of the lesions were:size (median 5 mm,min/max 2/30 mm), location (right colon=n°58; left colon=n°92), morphology according to Paris Classification (Ip=n°28, Is=n°78, IIa=n°42, IIa+IIc=n°1, III=n°1) and histology (adenomatous=n°118, hyperplastic=n°27, flogosis=n°3; submucosal=n°1, carcinoma=n°1). Mean sensitivity, specificity and accuracy of the 4 observers were (first vs second reading): 87.7%±3.2% (SD) vs 88.0%±6.7% (p=0.9), 61.7%±7.9% vs 67.5%±8.3% (p=0.3), 82.2%±1.5 vs 84.0%±5.3% (p=0.5) respectively.The Kappa value of interobserver agreement was 0.462 (95%CI 0.373-0.537) and the mean Kappa intraobserver agreement, evaluated after the second reading, was 0.657 (95%CI 0.3730.941).
S76 OC.09.5
ASSESSMENT OF THE UTILITY OF EARLY ENDOSCOPIC ULTRASOUND (EUS) IN THE EVALUATION OF ACUTE BILIARY PANCREATITIS (ABP): A PROSPECTIVE PILOT STUDY A. Anderloni ∗ , M. Galeazzi, M. Ballarè, M. Pagliarulo, S. Andorno, M. Del Piano Ospedale “Maggiore della Carità”, Novara, Italy Background and aim: ABP necessitates urgent diagnosis and treatment by endoscopic removal of common bile duct (CBD) stones. In clinical practice the decision to perform early ERCP is often based on biochemical and radiological criteria. EUS is not currently a worldwide standard diagnostic procedure early in the course of ABP, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions and therefore in preventing unnecessary ERCP. Aim: To investigate the clinical impact of early EUS in the management of ABP. Material and methods: From January 2010 to November 2011 all patients presenting to the A&E department with ABP were prospectively included in the study and were categorized into low, moderate, and high probability of CBD stones. Predicted severity of acute pancreatitis was assessed according to APACHE and Glasgow criteria. All the included patients underwent EUS within 48 hours from the admission. ERCP was performed immediately afterward if a biliary stone was identified. The following parameters were investigated: age, sex, fever, dilated CBD, bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (p<0.05) were entered in a multivariate logistic regression model. Results: 41 patients (21 female), mean age 62,3 (SD+16,9) were prospectively included in the study. 12 patients were classified as low probability of CBD stones, 14 as moderate probability and 15 as high probability. CBD stones were identified by EUS in 21 (51,2%) patients (4 with low probability, 7 with moderate probability and 10 with high probability) and confirmed at ERCP. 5 (33%) patients with high probability of CBD stones had a negative EUS. 28 patients had severe pancreatitis; among them 12 (43%) had CBD stones. Table 1 Positive Negative Total
Low
Moderate
High
Total
8 4 12
7 7 14
5 10 15
20 21 41
Conclusions: Our results confirm that commonly used biochemical and radiological predictors of the presence of CBD stones in patients with ABP are unreliable. Early EUS seems to be safe and accurate in identifying CBD stones, and can be used early in the management of ABP to select patients who would benefit from endoscopic treatment and to avoid unnecessary ERCP.
OC.09.6 A REAL-WORLD ANALYSIS OF THE OUTCOME OF PATIENTS WITH IPMN AND INDICATION FOR SURGERY ACCORDING TO INTERNATIONAL ASSOCIATION OF PANCREATOLOGY (IAP) CRITERIA IN WHOM SURGERY IS NOT PERFORMED M. Piciucchi ∗ ,1 , G. Capurso 1 , M. Del Chiaro 2 , M. Antonelli 1 , R. Valente 1 , M. Signoretti 1 , G. Zerboni 1 , G. Leonardi 2 , E. Iannicelli 1 , M. Cavallini 1 , V. Ziparo 1 , U. Boggi 2 , G. Delle Fave 1 1 Ospedale
S.Andrea, Università La Sapienza, Rome, Italy; 2 Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy Background and aim: PMNs are increasingly diagnosed incidentally, in patients with other diseases.The indication for surgery according with IAP criteria, may be difficult to be applied to elderly patients with incidental detection of IPMN, and/or major comorbidities. However, the outcome of
these patients who do not undergo intervention has not been investigated. We aim to assess the outcome of patients with IPMN and IAP criteria for resection, who did not receive surgery. Material and methods: Retrospective analysis of a cohort of IPMN, prospectively enrolled in 2 centers, to assess the different outcome of patients with an indication for surgery and potentially resectable IPMN who did, or did not underwent surgery. Results: According, to IAP guidelines, of 103 patients with IPMN (64 F, age: 70; 38-95), 30 (29,1%) had indication to surgery and resectable IPMN. 17 of these underwent resection (Group 1), whereas in 13 (Group 2) an observational follow up was preferred, due to comorbidities and/or advanced age. Indeed, patients in Group 2 were significantly older (median 77 yrs vs 71), more often had major comorbidities (61,53 vs 29,4%) and an incidental diagnosis (68% vs 41% in Group 1). 82% of Group 1 had an IPMN affecting the main duct as compared to 53.8% in Group 2. However, the final histology confirmed malignancy in only 29% of resected pts. Median survival after the therapeutic decision (surgery vs no surgery) was similar: 23 months in Group 1 vs 19 in group 2 (p=0,61). Survival assessed by Kaplan-Meier curve was not different in two groups (p=0,30). Mortality was 30,76% in Group 2 (4 pts died to disease progression) and 11,76% in Group 1, where 2 pts died due to surgical complications. 2 other pts in Group 1 had disease recurrence in the remnant pancreas during the follow-up. Conclusions: In this series, 43% of patients with IPMN and indication for surgery did not undergo intervention due to advanced age and/or major comorbidities. Although this therapeutic choice is not codified, it seems reasonable and not associated with a worse outcome. Such an option should be carefully discussed with patients, also keeping in mind that the rate of malignancy in this setting is as low as 30%.
OC.10.1 I-SCAN HIGH-DEFINITION WHITE LIGHT ENDOSCOPY AND COLORECTAL POLYPS: PREDICTION OF HISTOLOGY, INTEROBSERVER AND INTRAOBSERVER AGREEMENT F. Pigò ∗ , H. Bertani, M. Manno, V.G. Mirante, A. Caruso, C. Barbera, R. Manta, G. Olivetti, R.L. Conigliaro Nuovo Ospedale Civile Sant’Agostino Estense, Modena, Italy Background and aim: Progress of quality of videocolonoscopy increased recognition of non-neoplastic polyps with resulting added costs for pathological analysis and risks for the patient. I-Scan (Pentax® ,Japan), among virtual chromoendoscopic techniques, is a new tool for diagnosis and differentiation of colonic polyps. This imaging system, combined with high definition white light (HDWL) endoscopes, could increase the accuracy of diagnosis and lead to time/cost savings. The aim of the study was the evaluation of HDWL I-Scan endoscopy for diagnostic prediction of histology, inter- and intraobserver agreement for colorectal polyps. Material and methods: 150 images of polyps were consecutively collected during 78 colonoscopies. Pictures were taken with I-Scan (set-up: surface enhancement 4+ and tone enhancement p-/c-mode) and with HDWL colonoscopes. Four skilled endoscopists, not involved in the collection of cases, predicted the polyps’ histology (neoplastic vs non-neoplastic) and repeated the assessment after 6 months. Histology prediction was based on the evaluation of mucosal surface and vascular pattern. The inter- and intraobserver agreement were calculated by using the values of Kappa (Landis & Koch 1977): slight =0.2; fair 0.21-0.4; moderate 0.41-0.6; substantial 0.61-0.80 and almost perfect 0.81-1.00. Results: Characteristics of the lesions were:size (median 5 mm,min/max 2/30 mm), location (right colon=n°58; left colon=n°92), morphology according to Paris Classification (Ip=n°28, Is=n°78, IIa=n°42, IIa+IIc=n°1, III=n°1) and histology (adenomatous=n°118, hyperplastic=n°27, flogosis=n°3; submucosal=n°1, carcinoma=n°1). Mean sensitivity, specificity and accuracy of the 4 observers were (first vs second reading): 87.7%±3.2% (SD) vs 88.0%±6.7% (p=0.9), 61.7%±7.9% vs 67.5%±8.3% (p=0.3), 82.2%±1.5 vs 84.0%±5.3% (p=0.5) respectively.The Kappa value of interobserver agreement was 0.462 (95%CI 0.373-0.537) and the mean Kappa intraobserver agreement, evaluated after the second reading, was 0.657 (95%CI 0.3730.941).