Faculty Bibliography

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that carry a risk of malignant transformation to pancreatic ductal adenocarcinoma (PDAC). Guidelines have been evolving to best identify which criteria should qualify a patient for resection and which cysts can safely remain under surveillance. Our aim was to understand which baseline cyst and patient features predict disease progression and malignant transformation. Aims & Methods: Patients with clinically suspected IPMN who did not meet consensus criteria for resection at diagnosis and were surveyed for at least 12 months or underwent surgery after a minimum surveillance of 3 months were included. All patients evaluated by radiologic studies or endoscopic ultrasound between 1998 and 2015 were included. We defined progression as either an increase in size of the dominant cyst >=20% or >=2mm or the development of worrisome features (mural nodule or mass, thick septations, main duct involvement or high grade dysplasia or cancer on cytology or surgical pathology). Statistical analysis was performed with the Chi square and Fisher exact tests for categorical variables and Mann-Whitney U test for continuous variables. All covariates of interest with p<0.05 in the univariate analysis were included in the logistic regression model. Result: male gender, a history of prostate cancer and diabetes, weight loss and initial cyst size >2 cm. A history of prostate cancer, diabetes, weight loss, elevated cyst fluid CEA and cyst size >2 cm were associated with development of worrisome features. In logistic regression analysis, a history of prostate cancer (OR 2.9; 95% CI 1.7-7.7) and weight loss (OR 2.47; 95% CI 1.18-6.1) were associated with development of worrisome features (p<0.05). There were no baseline predictors of cyst size increase alone. Baseline characteristics such as race, smoking or alcohol use, a strong family history of PDAC, multifocality and location of cysts were not associated with increased disease progression. Conclusion: In the largest multicenter surveillance study of low risk IPMNs to date, we showed that 41% of suspected IPMNs increased in size only, 9% developed worrisome features and 2% developed high-grade dysplasia or cancer. Among baseline characteristics, none were predictive of size increase. A personal history of prostate cancer and weight loss were the strongest predictors of the development of worrisome features. (Table Presented)

BACKGROUND AND STUDY AIMS: Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome. PATIENTS AND METHODS: This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared. RESULTS: A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups. CONCLUSIONS: Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration.

GOALS: To describe a multicenter experience using an endoscopic suturing device for management of gastrointestinal (GI) defects and stent anchorage. BACKGROUND: Endoscopic closure of GI defects including perforations, fistulas, and anastomotic leaks as well as stent anchorage has improved with technological advances. An endoscopic suturing device (OverStitch; Apollo Endosurgery Inc.) has been used. STUDY: Retrospective study of consecutive patients who underwent endoscopic suturing for management of GI defects and/or stent anchorage were enrolled between March 2012 and January 2014 at multiple academic medical centers. Data regarding demographic information and outcomes including long-term success were collected. RESULTS: One hundred and twenty-two patients (mean age, 52.6 y; 64.2% females) underwent endoscopic suturing at 8 centers for stent anchorage (n=47; 38.5%), fistulas (n=40; 32.7%), leaks (n=15; 12.3%), and perforations (n=20; 16.4%). A total of 44.2% underwent prior therapy and 97.5% achieved technical success. Immediate clinical success was achieved in 79.5%. Long-term clinical success was noted in 78.8% with mean follow-up of 68 days. Clinical success was 91.4% in stent anchorage, 93% in perforations, 80% in fistulas, but only 27% in anastomotic leak closure. CONCLUSIONS: Endoscopic suturing for management of GI defects and stent anchoring is safe and efficacious. Stent migration after stent anchoring was reduced compared with published data. Long-term success without further intervention was achieved in the majority of patients. The role of endoscopic suturing for repair of anastomotic leaks remains unclear given limited success in this retrospective study.

BACKGROUND:Brush cytology is the initial intervention when evaluating biliary strictures. Biliary brush cytology is known for its low sensitivity (but high specificity) and may be accompanied by biopsies and/or fluorescent in situ hybridization (FISH) to improve diagnostic yield. This study aimed to identify features to enhance cytological sensitivity, and assess which sampling method(s) improve identification of pancreatobiliary adenocarcinomas (PBCa). METHODS:Seventy-three biliary stricture cases were retrieved (38 PBCa and 35 control benign strictures). Biliary brushings, FISH, and biopsies were reviewed. Cytology specimens were evaluated for cellularity and presence of drunken honeycomb (DH), loosely cohesive clusters of round cells (LCCRC), large atypical cells with foamy cytoplasm (LACF), and single vacuolated malignant cells (SCs). Biopsies were examined for the presence of stromal invasion (SI). RESULTS:Biliary brushings were scantly cellular in 47.4% of PBCa and 51.4% of controls, resulting in 69.6% nondiagnostic/false-negative cytology diagnoses. DH, LACF, and SCs were significantly associated with adenocarcinoma (P < .00001, .0033, and .00002, respectively). By univariate analysis, SCs and LACF were predictors of malignancy in brushings (P = .0002 and .05). By multivariate analysis, only SCs were predictive of malignancy (P = .002). SI facilitated the diagnosis in 9 biopsies. Sensitivity/specificity of brush cytology, FISH, and biopsy were 39.5%/94.3%, 63.9%/94.3%, and 84.2%/100%, respectively. CONCLUSIONS:The low sensitivity of biliary brushings results from limited cellularity. Identification of LACF, DH, and SCs improves sensitivity. Sampling of stromal tissue may facilitate PBCa diagnosis. Concurrent biopsies and FISH are helpful in enhancing the diagnostic yield of PBCa.

OBJECTIVES/OBJECTIVE:This study compares the progression of multifocal (MF) intraductal papillary mucinous neoplasms (IPMNs) to unifocal (UF) lesions. METHODS:We performed a retrospective review of demographics, risk factors, and cyst characteristics of a prospectively maintained database of 999 patients with pancreatic cysts. Patients included had IPMN under surveillance for 12 months or more. Those with high-risk stigmata were excluded. Cyst size progression and development of worrisome features were compared between MF and UF cohorts. We evaluated whether the dominant cyst in MF-IPMN had more significant growth than did the other cysts. RESULTS:Seventy-seven patients with MF-IPMN and 54 patients with UF-IPMN, with mean follow-up of 27 and 34 months, met the criteria. There were no significant differences between demographics, risk factors, or initial cyst sizes. Fifty-seven percent of MF dominant cysts and 48% of UF cysts increased in size (P = 0.31). Progression in MF was more likely in the dominant cyst (P < 0.05). There were no significant differences in the development of mural nodules or increase in cyst size to more than 3 cm. CONCLUSIONS:Demographics of both cohorts were similar, as was the overall incidence of worrisome features. Because meaningful size progression primarily occurred in the dominant cyst, our findings support surveillance based on the dominant cyst in MF disease.