Role of endoscopic ultrasonography and fine needle aspiration in the managment of pancreatic masses

Introduzione: Nelle ultime due decadi l’ecoendoscopia (EUS) ha assunto un ruolo di fondamentale importanza nella valutazione diagnostica del pancreas. Nella diagnosi e nella stadiazione locale delle neoplasie pancreatiche di dimensioni inferiori a 2 cm essa si è dimostrata superiore rispetto alla TC ed alla RMN. Inoltre l’utilizzo dell’ago-aspirato eco-guidato (EUS-FNA) permette l’acquisizione di tessuto dalla lesione bersaglio mediante ago biopsia eco-guidata. Nonostante una prevalenza relativamente ridotta, il cancro del pancreas presenta uno dei più bassi tassi di sopravvivenza a 5 anni, che si attesta intorno al 5%. Questo aspetto è chiaramente correlato non solo al ritardo nella comparsa dei sintomi ma anche alle limitate strategie di trattamento attualmente a disposizione. Uno dei principali obiettivi dell’ agoaspirato eco-guidato (EUS-FNA) è quello di garantire la diagnosi di neoplasie di sospetta natura maligna in uno stadio precoce. Obiettivi: Lo Scopo dello studio è quello di valutare il ruolo dell’ EUS-FNA e dell’ EUS-FNB nella diagnosi e nella stadiazione di lesioni pancreatiche maligne . Lo studio intende, inoltre, analizzare i fattori ( legati alla lesione, alla procedura o all’ operatore) che ne influenzano sensibilità e specificità. Un ulteriore obiettivo consiste, infine, nel valutare l’outcome a distanza nei pazienti con un esame EUS-FNA negativo, evidenziando i possibili fattori che possano predire risultati falsi negativi. Materiali e Metodi: La popolazione di studio includerà tutti i pazienti che vengono sottoposti a EUS- FNA per presenza di lesioni pancreatiche sospette. Le indicazioni all’ eco-endoscopia pancreatica comprenderanno: dilatazione/stenosi del dotto epatico comune o del dotto pancreatico alle immagini (CT, CPRE, colangio RMN), pancreatite acuta o cronica diagnosticata clinicamente o radiologicamente (CT, RX, colangio RMN) presenza di masse o cisti (alla TC o alla RMN), ittero ostruttivo, elevati valori di CA 19.9 (range di normalità tra 0 U/mL a 37 U/mL) e/o perdita di peso. In ciascuna procedura verranno registrati i dati del paziente, le indicazioni per l’ecoendoscopia pancreatica o per l’EUS-FNA, le caratteristiche ecografiche della lesione, la descrizione della procedura stessa, le eventuali complicanze intra o post- procedurali e la diagnosi definitiva. Dal 1 Settembre sono stati introdotti dei nuovi aghi fenestrati ( EchoTip® Procore Cook Medical) che permettono l’acquisizione di un frustulo di tessuto tale da garantire una EUS-FNB garantendo quindi una valutazione istologica dei campioni prelevati. Risultati : Durante il periodo di studio sono state eseguite 71 procedure di FNB su un totale di 382 esami ecoendoscopici. 2 pazienti sono stati esclusi dallo studio in quanto presentavano al momento della procedura una substenosi duodenale da compressione neoplastica ab estrinseco tale da non permettere l’avanzamento dello strumento fino in terza porzione duodenale. La popolazione in esame ha preso in considerazione 69 pazienti (36M e 33F) con età media di 72 anni (range 46-86 aa). L’esecuzione della procedura eco-endoscopica e della FNB è stata possibile in 68 casi su 69. In 1 paziente non è stato possibile effettuare la FNB per la difficile localizzazione della lesione e per la scarsa compliance del paziente. Il successo tecnico è stato del 98.5% (68 su 69) garantendo l’acquisizione di microfrustoli tissutali giudicati, in base ad una valutazione macroscopica in corso di procedura eseguita dall’operatore stesso, idonei per una diagnosi istologica. Le lesioni pancreatiche erano localizzate a livello della testa in 35/69 casi (50.7%), del corpo pancreatico in 21/69 (30.4%), dell’istmo in 5/69 dei casi (7.3%), del processo uncinato e della coda in 4/69 casi rispettivamente (5.8%). Il diametro medio delle lesioni era di 28.3mm (range 12-50 mm). Per lesioni con diametro superiore a 50 mm la valutazione dimensionale tramite EUS era inficiata dalla ridotta penetrazione degli ultrasuoni. L’ FNB è stata effettuata con un approccio trans-duodenale in 40/69 (58%) dei casi e con approccio trans-gastrico nei restanti 29/69 (42%) dei casi. Sono stati effettuati una media di 3.5 passaggi per lesione (range 2-6). In 64 pazienti su 69 (92.7% dei casi) i campioni prelevati tramite FNB si sono rilevati adeguati al fine di una valutazione istologica. In 5 pazienti il materiale acquisito non ha permesso un’idonea valutazione istologica, data l’inadeguatezza dello stesso. Una diagnosi istologia definitiva è stata ottenuta in 59 pazienti (85,5% della popolazione in esame). L’esecuzione della FNB ha permesso di ottenere le seguenti diagnosi: - 44 adenocarcinomi del pancreas; - 6 Tumori Neuroendocrini del Pancreas (NET); - 3 Tumori della Via Biliare PrincipaleAdenocarcinomi della papilla di Vater; - 1 metastasi pancreatica da cellule renali; - 5 casi di tessuto pancreatico morfologicamente compatibile con pancreatite cronica. Dei 5 pazienti con diagnosi di pancreatite cronica 2 sono stati sottoposti ad intervento chirurgico per sospetta progressione clinica e radiologica di malattia neoplastica con diagnosi conclusiva per adenocarcinoma pancreatico alla valutazione istologica del pezzo operatorio. I 5 pazienti con inadeguato campionamento alla FNB e i 5 pazienti senza una diagnosi istologica definitiva sono stati sottoposti, dato il forte sospetto clinico di lesione neoplastica, ad una nuova FNB dopo un periodo medio di 34 gg (range 20-43gg). La ripetizione del FNB ha permesso di eseguire diagnosi di 8 adenocarcinomi del pancreas e di 1 tumore neuroendocrino. La conferma istologica di tessuto neoplastico è stato considerata come una diagnosi conclusiva. Nelle FNB negative per cellule neoplastiche, invece, la diagnosi conclusiva per 25 patologia benigna è stata formulata dopo un follow-up clinico e radiologico di minimo 6 mesi o dopo la valutazione istologica del pezzo operatorio. Nel nostro studio l’EUS-FNB ha mostrato una sensibilità, specificità ed accuratezza rispettivamente del 81%, 100% e 83%

Is the human acetabulofemoral joint spherical?

The human acetabulofemoral joint is commonly modelled as a pure ball-and-socket joint, but there has been no quantitative assessment of this assumption in the literature. Our aim was to test the limits and validity of this hypothesis. We performed experiments on four adult cadavers. Cortical pins, each equipped with a marker cluster, were implanted in the pelvis and the femur. Movements were recorded using stereophotogrammetry while an operator rotated the cadaver’s acetabulofemoral joint, exploiting the widest possible range of movement. The functional consistency of the acetabulofemoral joint as a pure spherical joint was assessed by comparing the magnitude of the translations of the hip joint centre as obtained on cadavers, with the centre of rotation of two metal segments linked through a perfectly spherical hinge. The results showed that the radii of the spheres containing 95% of the positions of the estimated centres of rotation were separated by less than 1 mm for both the acetabulofemoral joint and the mechanical spherical hinge. Therefore, the acetabulofemoral joint can be modelled as a spherical joint within the considered range of movement (flexion/extension 20° to 70°; abduction/adduction 0° to 45°; internal/external rotation 0° to 30°)

Difficult biliary stones in the elderly. Endoscopic retrograde cholangiography. A single surgical tertiary centre experience with follow-up

Background: Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of 'difficult' biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones.Materials and Methods: From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A - aged 85 years or older (n = 110) and Group B - aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported.Results: Chronic comorbidities (86.3% vs. 24.2%; P < 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P < 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P > 0.6) and complication rate (8.2% vs. 13%; P > 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P < 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P < 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P > 0.5). PAD was identified as the risk factor for recurrence (P < 0.02).Conclusion: ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones

Hip joint centre location: an <i>ex vivo</i> study

The human hip joint is normally represented as a spherical hinge and its centre of rotation is used to construct femoral anatomical axes and to calculate hip joint moments. The estimate of the hip joint centre (HJC) position using a functional approach is affected by stereophotogrammetric errors and soft tissue artefacts. The aims of this study were (1) to assess the accuracy with which the HJC position can be located using stereophotogrammetry and (2) to investigate the effects of hip motion amplitude on this accuracy. Experiments were conducted on four adult cadavers. Cortical pins, each equipped with a marker cluster, were implanted in the pelvis and femur, and eight skin markers were attached to the thigh. Recordings were made while an operator rotated the hip joint exploiting the widest possible range of motion. For HJC determination, a proximal and a distal thigh skin marker cluster and two recent analytical methods, the quartic sphere fit (QFS) method and the symmetrical centre of rotation estimation (SCoRE) method, were used. Results showed that, when only stereophotogrammetric errors were taken into account, the analytical methods performed equally well. In presence of soft tissue artefacts, HJC errors highly varied among subjects, methods, and skin marker clusters (between 1.4 and 38.5 mm). As expected, larger errors were found in the subject with larger soft tissue artefacts. The QFS method and the distal cluster performed generally better and showed a mean HJC location accuracy better than 10 mm over all subjects. The analysis on the effect of hip movement amplitude revealed that a reduction of the amplitude does not improve the HJC location accuracy despite a decrease of the artefact amplitude

P69 - Biological prostheses for complex abdominal wall repair

.Reconstruction of complex hernias of abdominal wall can be asso- ciated with a high complication rate. Placement of synthetic prosthetic mesh in a contaminated/potentially contaminated field may lead to infection and subsequent mesh removal. In these cases, bio- logical meshes could be used. These new materials are all essentially composed of an extracel- lular matrix without its cellular components and substantially differ in their source (porcine small intestine submucosa, porcine dermis or cadaveric human dermis) and in cross-linking. From March 2007 fifteen patients underwent repair of complex hernias of abdominal wall with biological meshes. Indications included patients treated with immunosuppressive therapies following liver or kidney transplantation (3 cases), immunologic diseases (2 cases), synchronous colonic surgery (4 cases), acute cholecystitis (4 cases) and treatment of parastomal hernia (2 cases). On two patients with parastomal hernia, a midline hernia (in both cases) and a perineal hernia (in one case) were associated. In all cases cross-linked porcine dermal collagen meshes (13 Permacol, Covidien and 5 Colla Mend, Bard) were used. Complications occurred in 3 patients (1 abdominal wall abscess, 1 intra-abdominal abscess, 1 haematoma) requiring a second surgical look but despite of the presence of contamination it was unnecessary to remove the mesh. At follow-up (min 3 mos.- max 22 mos) no recurrence or bulging were observed. Biological meshes can be used in patients in which the use of synthetic materials might be problematic such as (potentially) con- taminated environment or immunologic problems. Although no large series are actually available in literature, from preliminary data they seem to represent a safe and acceptable alternative in such circum- stances. The European Hernia Society (EHS) Registry for Biological Prostheses (ERBP) will allow to better understand the current use and outcome of biological meshes (Hernia 2009, 13:103–108)

Early ‘shallow’ needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla

Introduction: Needle-knife sphincterotomy (NKS), known as ‘precut’, is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. Methods: From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. Results: Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. Conclusion: In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications