A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single-center case series with long-term results

Background

Minimally invasive techniques for treating pilonidal disease are safe and effective alternatives to conventional surgery, with improved recovery time, cosmetic results, and pain control. The aim of this study was to evaluate the 5-year surgical outcomes of a single-center case series treated with endoscopic pilonidal sinus treatment (EPSiT).

Methods

We conducted a retrospective single-center analysis of all patients treated with EPSiT, by a single surgical team, from March 2015 to December 2019, for primary or recurrent pilonidal disease. The primary outcomes were recurrence, persistence and treatment failure. The secondary outcomes were postoperative pain, painkiller use, time off work, satisfaction, complications, wound healing time, time to persistence or recurrence.

Results

Forty-two patients underwent 46 EPSiT procedures [34 males, 8 females, median age 25 (IQR 13.75) years] for primary (47.8%) or recurrent pilonidal disease (52.2%). All patients completed the follow-up [median 62 (IQR 43) months]. The single procedure healing rate was 76.1%. The healing rate for the first procedures plus the second EPSiT procedure (performed in 4 cases) was 83.3%. Among the 46 EPSiT procedures, we recorded six cases of persistence (13.0%) and five cases of recurrence (10.9%) The median operative time was 32.5 (IQR 18.75) minutes, the median pain score (visual analog scale) in week 1 was 2 (IQR 2), and the median time off work was 4 (IQR 2) days. Four patients (8.7%) experienced complications: serosanguineous (n?=?2) or seropurulent discharge (n?=?2). The satisfaction rate was 95.7%.

Conclusions

In our experience, EPSiT is safe, well accepted. and associated with a low level of postoperative pain, short hospitalization, short time off work, as well as optimal cosmetic results. Its failure rate is similar to that of excisional surgery.

     

Hepatic micrometastases outside macrometastases are present in all patients with ileal neuroendocrine primary tumour at the time of liver resection

Abstract

Background: Neuroendocrine tumours (NETs) in the ileum grow slowly but metastasise to the liver at an early stage. After resection of the primary tumour and mesenteric lymph nodes, selected patients with liver metastases have been operated with curative intention. Recurrence-free survival seems low, suggesting that micrometastases are present in the liver at the time of surgery. We have therefore examined whether NET metastases could be detected in perceived normal liver tissue at the time of liver resection.

Material and methods: Liver tissue outside the macrometastases from patients (n?=?10) operated by liver resection due to metastases from ileal NETs G1/2, were examined for NE cells by immunohistochemistry. Liver tissue from patients operated for metastatic colon cancer was used as control (n?=?6). Groups of ≥3 NE cells ≥3?mm from macrometastases were considered micrometastases. Clinical course was recorded retrospectively.

Results: Ten of 10 patients had micrometastases, consisting of multiple groups of NE cells. None of the control patients had NE cells in the liver tissue. After median follow-up time of 5.5 (0.8–18.7) years 6 of 10 patients had developed recurrent NET metastases detected by cross-sectional imaging. The follow-up time of the four patients without detectable metastases was 4.8 (0.8–7.5) years vs. with detectable metastases 7.9 (3.2–18.7) years.

Conclusions: All patient had micrometastases outside macrometastases at the time of liver resection, suggesting that subsequently recurrent liver metastases develop from NET depositions in the liver already present at the time of surgery. The likelihood of curation by hepatic resection appears very low.     

Elective surgery should be considered after successful conservative treatment of recurrent diverticular abscesses

Abstract

Purpose: The purpose of this study was to evaluate the disease pattern and treatment of diverticular abscesses.

Methods: Patients treated for diverticulitis (K57) in Västmanland, Sweden were identified for this retrospective population-based study between January 2010 and December 2014. Patients with diverticular abscesses were included. The clinical and radiological data were extracted, and the computed tomography scans were reevaluated.

Results: Of the 75 patients (45 women) with a median age of 62?years (range: 23–88?years), abscesses were localized pericolic in 42 patients (59%) and in the pelvis in 33 patients (41%). The median abscess size was 4.8?cm (range: 1.1–11.0?cm). Six patients (8%) required urgent surgical intervention during the index admission. The median follow-up time was 58?months (range: 0–95?months). During follow-up, 40 patients (58%) had disease recurrence and 35 of these patients (88%) presented with complicated diverticulitis. The median time until re-admission was 2?months (range: 3?days–94?months). Patients with pelvic abscesses developed fistulas more frequently, 3 versus 11 patients (p?=?.003). Twenty-three percent of patients with pericolic abscesses required surgery compared with 40% of patients with pelvic abscesses (p?=?.09). No patients had a recurrence of abscesses after a colonic resection.

Conclusion: The majority of patients with diverticular abscesses had recurrences with repeated admissions regardless of abscess location. An unexpectedly high proportion of patients required surgical intervention during the follow-up period. A liberal approach regarding elective surgery for patients with recurrent diverticulitis abscesses who tolerate surgery seems justified.     

The role of surgery in patients aged 85 years or older with resectable gastric cancer: a propensity score matching analysis of the SEER database

Abstract

Introduction: An increasing number of newly diagnosed resectable gastric cancer (GC) patients are over 85?years of age. However, studies on surgical treatment in these patients are limited. This study aimed to explore the prognosis of a large sample of the oldest old GC patients receiving surgery.

Methods: A total of 2914 oldest old patients with stage I-III GC were included in the linked Surveillance, Epidemiology, and End Results (SEER) database from 2006 to 2015. Based on their treatment, we assigned these patients to the surgery and no surgery groups. We used propensity score matching (1:1) to balance the baseline characteristics. The Kaplan–Meier method was used for the survival analysis. Multivariate Cox regression analysis was used to analyse the independent risk factors.

Results: After propensity score matching, the median overall survival (OS) times in the surgery and no surgery groups were 24.0 (95% CI: 20.3–27.7) and 4.0 (95% CI: 3.5–4.5) months, respectively (p?<?.01). Age, sex, stage, histological type, and treatment with surgery and chemotherapy were independent risk factors for OS in the oldest old patients with GC. In total, 19% of the oldest old patients with GC died from causes unrelated to cancer.

Conclusions: The current large-scale study demonstrated that the oldest old patients with stage I-III GC could benefit from elective surgery.     

Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature*

Background and aim: Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting.

Patients and method: Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal.

Results: Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6–10?mm, 4–8?cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2–105) days. The median hospital stay was of 10 (4–21) days. Median time to post-operative feeding was 4 days (2–15).

Conclusion: FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.     

Relationship between disease activity and patient-reported outcomes in rheumatoid arthritis: Post hoc analyses of overall and Japanese results from two phase 3 clinical trials

Abstract

Objective: To examine patient-reported outcomes (PROs) in patients with different rheumatoid arthritis (RA) disease activity levels and identify residual symptoms.

Methods: Post hoc analyses of overall and Japanese data from two randomized controlled trials including RA patients with previous inadequate responses to methotrexate (NCT01710358) or no/minimal previous disease-modifying antirheumatic drug treatment (NCT01711359) (sponsor: Eli Lilly and Company). Week 24 assessments were disease activity (Simplified Disease Activity Index, Disease Activity Score/Disease Activity Score 28 joints-erythrocyte sedimentation rate) and PROs (pain visual analog scale [VAS], morning joint stiffness [MJS], Health Assessment Questionnaire-Disability Index, Functional Assessment of Chronic Illness Therapy-Fatigue, and Medical Outcomes Study Short Form 36 Health Survey Physical and Mental Component Scores).

Results: Patients achieving remission/low disease activity (LDA) at Week 24 had larger/significant improvements from baseline in pain, MJS, disability, fatigue, and physical and emotional quality of life versus patients with high/moderate disease activity. Some patients achieving remission and LDA, reported residual pain (pain VAS >10?mm): 20.8–39.3% and 48.7–70.0% (overall study populations), 16.0–34.5% and 47.1–62.0% (Japanese patients). Residual MJS and fatigue were also reported.

Conclusion: Remission/LDA were associated with improvements in PROs in overall and Japanese patient populations; however, some patients achieving remission had residual symptoms, including pain.     

Quality of care evaluation in non-functioning pituitary adenoma with chiasm compression: visual outcomes and timing of intervention clinical recommendations based on a systematic literature review and cohort study

Purpose

Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown.

Methods

Systematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed.

Results

Systematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay.

Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5?±?14.8 years), had a median MD of???5.3 decibel (IQR???3.1 to???10.1). MD was strongly correlated with clinical severity (r?=????0.94, P?<?0.0001), and were used for severity of defects cut-off values: (1) normal?>????2 dB, (2) mild???2 dB to???4 dB, (3) moderate???4 to???8 dB, (4) severe???8 to???17 dB, (5) very severe?<????17 dB.

Conclusion

Surgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.

     

Pancreaticoduodenectomy for paraduodenal pancreatitis is associated with a higher incidence of diabetes but a similar quality of life and pain control when compared to medical treatment

BackgroundParaduodenal pancreatitis is a focal form of chronic pancreatitis that affects the groove area between the duodenum and the head of the pancreas. Consensus regarding surgical or nonsurgical management as the best treatment option is still lacking.MethodsWe retrospectively evaluated all patients managed for PP at The Pancreas Institute of the University Hospital Trust of Verona from 1990 to 2017. The outcomes of surgical vs. medical treatment with regard to pain control, quality of life and pancreatic insufficiency were evaluated through specific questionnaires.ResultsThe final study population consisted of 75 patients: 62.6% underwent surgery, and 37.4% were managed without surgery. All surgical procedures consisted of pancreaticoduodenectomy. The median follow-up from the diagnosis of paraduodenal pancreatitis was 60 (12–240) months. Patients who underwent surgery experienced a similar incidence of steatorrhea (44.7 vs. 52.6%; p = 0.4) but a significantly higher incidence of diabetes (59.6 vs. 10.7%; p < 0.01) when compared to those managed without surgery. There was no difference in terms of reported chronic pain (Graded Chronic Pain Scale, median 0 vs. 1; p = 0.1) and quality of life (Pancreatitis QoL Instrument, median 82 vs. 79; p = 0.2). However, surgical patients reported a worse level of self-care activities associated with glycemic control (Diabetes Self-Management Questionnaire, median 20 vs. 28, p = 0.02).ConclusionIn patients affected by paraduodenal pancreatitis, surgery and medical therapy seem to obtain similar results in terms of quality of life and pain control. However, surgery is associated with an increased prevalence of postoperative diabetes with consequent relevant issues with self-care management. Surgery should be considered only in selected patients after adequate medical treatment.     

Early prediction for over two years efficacy of the first biologic agent for polyarticular juvenile idiopathic arthritis: A multi-institutional study in Japan

Objective: To estimate target of treatment for long-term efficacy of the first biologic agent used to treat polyarticular juvenile idiopathic arthritis (pJIA).

Methods: A retrospective cohort of patients with pJIA treated at six medical institutions in Japan between 1 March 2005 and 31 October 2014 was identified. The patients were divided by 2-year treatment periods with the first biologic agent into continuous treatment group and switching group. Three markers were examined: matrix metalloproteinase-3 (MMP-3), erythrocyte sedimentation rate (ESR), and disease activity score (DAS) 28-ESR.

Results: Thirty-two pJIA patients (8 boys, 24 girls) from 43 recruited patients were included in this study. The treatment periods with the first biologic agent in continuous treatment group (24 patients, 75%) was 40 months (median, range 24–119) and switching group (8 patients; 25%) was 9.5 months (median, 6–18). Markers [odds ratio (95% confidence interval)] at 3 months were MMP-3 [1.02 (0.99–1.05), p?=?.219], ESR [1.00 (0.78–1.30), p?=?.998], and DAS28-ESR [13.9 (2.08–409.82), p?=?.035]. The cut-off point for DAS28-ESR at 3 months to distinguish the two groups was 2.49 (sensitivity, 87.5%; specificity, 87.5%).

Conclusion: DAS28-ESR of 2.49 at 3 months after initiating the first biologic agent can be a target of sustained treatment in pJIA patients.     

Long-term results of combined ESWL and ERCP treatment of chronic calcific pancreatitis

Objective: Extracorporeal shock wave lithotripsy (ESWL) combined with endotherapy (ET) is the standard treatment for pancreatic duct stones (PDS) in chronic pancreatitis (CP). Our aim was to report the short- and long-term results of ESWL and ET.

Material and methods: Consecutively treated 83 patients with symptomatic PDS using ESWL and ET. Success was defined (i) technically: PDS fragmentation and clearance obtained and (ii) clinically: improvement/resolution of pain. To get information on quality of life, we conducted a phone survey whereby we contacted 64 (89%) patients. The long-term results are presented in those patients with ≥2 years follow-up.

Results: Treated PDS with median size of 10 (5–25) mm were located in the head, body, or the tail of the pancreas in 78, 4, and 1 patients, respectively. The primary results were that technical success was achieved in 69 patients (83%) and clinical success in 66 patients (80%). Fourteen patients had technical failure, but eight of them became free of pain. Thus, clinical success can be considered to have been achieved in 74 of 83 patients (89%). In patients with persistent pseudocyst (PC) at the time of ESWL (n?=?19), the PC disappeared in a year in 14 patients (74%). The long-term results were obtained from 61 (73%) ESWL- and ET-treated patients. The median follow-up for them was 53 months (range: 24–124) and 57 patients (93%) became pain-free or had less pain.

Conclusions: For patients with CP and PDS ESWL combined with ET is an effective and safe treatment giving favorable long-term results.     

Dyspareunia is associated with chronic pain in premenopausal women with sickle cell disease

Objectives: Pain is common in women with sickle cell disease (SCD), but the prevalence of dyspareunia in this unique patient population is unknown. In this study, we sought to determine whether chronic pain is associated with an increased prevalence of dyspareunia in premenopausal women with SCD.

Methods: A cross-sectional study of premenopausal women with SCD was systematically assessed for symptoms of dyspareunia and chronic pain using a standard questionnaire. These results were correlated with each subject's clinical pain phenotype determined by a review of the patient's electronic medical record.

Results: Ninety-one premenopausal women with SCD were examined. Thirty-two percent of the women reported dyspareunia. Women with dyspareunia were more likely to have a history of chronic pain (90% versus 61%, p?=?.006), report more pain days per week (median (interquartile range): 6 (4–7) vs. 3 (0–7), p?=?.005)), and had a higher oral morphine equivalent dose (145 (45–226) mg vs. 60 (9–160) mg, p?=?.030). Using a multivariable classification tree analysis, number of days of pain experienced per week was an important predictor of dyspareunia (p?=?.001).

Conclusion: Dyspareunia is common in women with SCD, and more common in women with SCD and chronic pain. Providers should assess women with SCD for dyspareunia, especially those with a chronic pain syndrome.     

Treatment of locally advanced pancreatic cancer with irreversible electroporation – a Danish single center study of safety and feasibility

Objectives: Irreversible electroporation (IRE) is a novel non-thermal ablative technique applied in the treatment of unresectable locally advanced pancreatic cancer (LAPC). This paper reports on the initial experience with IRE of unresectable LAPC in our institution.

Methods: From October 2013 to March 2018, patients with unresectable LAPC referred for IRE at the Department of Gastrointestinal Surgery, Aalborg University Hospital, were considered for inclusion in the study. Ninety-day morbidity, 30-day mortality, pain score, length of hospital stay (LOS) and overall survival (OS) were recorded.

Results: We included 33 patients receiving 40 IRE ablations in total. The median visual analogue scale (VAS)-score was four (range 0–10) two hours after IRE, and one (range 0–8) eight hours after IRE. The median LOS was one day (range 1–13 days). Post-procedural complications occurred in 21 of 40 ablations (53%), of which eight (20%) were major (Clavien–Dindo grade III or more). A proportion of the observed complications might be attributed to disease progression and not IRE per se. Although not statistically significant, we observed increased severity of complications in tumors above 3.5?cm. The 30-day mortality was 5% (2/40). The median OS was 10.7 months (range 0.6–53.8 months) from the initial IRE procedure, and 18.5 months (range 4.9–65.8 months) from time of diagnosis.

Conclusions: In our institution, IRE seems as a feasible consolidative treatment of unresectable LAPC with an acceptable safety profile. The oncological outcome of IRE in patients with unresectable LAPC is to be further evaluated in a planned phase 2 clinical trial (CHEMOFIRE-2).     

Laparoscopic lateral pelvic lymph node dissection combined with removal of the internal iliac vessels in rectal cancer: how to standardize this surgical procedure

Background

Lateral pelvic lymph node dissection (LLND) combined with removal of the internal iliac vessels is a challenging surgical procedure in minimally invasive surgery. We herein report our dissection approach and short-term outcomes.

Methods

We conducted a study on rectal cancer patients who underwent laparoscopuic LLND combined with removal of the internal iliac vessels at our institution in March 2017–December 2019. In performing the surgery, we identified and dissected along the three pelvic sidewall fasciae (ureterohypogastric, umbilical prevesical and parietal pelvic fascia), located the internal ilial vein at the level of the common iliac vessels and carried out our dissection along the medial anterior surface of the internal iliac before transecting the vein. The duration of LLND was recorded as was the blood loss.

Results

There were 16 patients (10 males, mean age 65.4?±?10.8 years). Five patients had primary surgery, and 11 had surgery for recurrence. The median blood loss of LLND was 10 ml (range, 0–250 ml), the median operating time was 173 min (range, 65–358 min), and post-operative complications were relatively mild. Seven of 16 patients (43.8%) were diagnosed with positive lateral nodes. The 2-year local recurrence-free and disease-free survival rates were 87.5% and 58.0%.

Conclusion

Recognizing the pelvic anatomical points illustrated in the present study contributes to the surgical safety of LLND combined with removal of the internal iliac vessels.

     

Risk factors for surgery in patients with retention of endoscopic capsule

Objectives: Surgery is still the main means for removing retained endoscopic capsules. This study intended to evaluate risk factors for surgery in patients with capsule retention.

Materials and methods: The data of 5348 consecutive capsule endoscopy examinations were retrospectively analyzed. Cox regression analysis was used to evaluate risk factors.

Results: Seventy-seven patients (1.4%) had capsule retention. Spontaneous passage occurred in 16 patients, of which 14 were asymptomatic. Successful retrieval by double-balloon enteroscopy (DBE) was achieved in 14 patients, of which 11 did not need surgery during clinical follow-up. A total of 50 patients underwent surgery. The cumulative rates of surgery were 44.2%, 53.2%, 55.8%, 62.3% and 64.9% at 1, 3, 6, 12 and 60 months after capsule retention, respectively. Intestinal obstruction [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.12–3.76; p?=?.020] and overt small bowel bleeding (HR 2.01, 95%CI 1.08–3.71; p?=?.027) during capsule retention were independently associated with an increased risk for surgery. Specific treatment for primary disease (HR 0.22, 95%CI 0.07–0.74, p?=?.014) and successful endoscopic retrieval (HR 0.20, 95%CI 0.06–0.66; p?=?.008) were independently associated with a decreased risk for surgery.

Conclusions: For asymptomatic patients, specific medical treatment for primary disease can be maintained until the capsule spontaneously passes or symptoms appear. For patients with slight abdominal pain, DBE can be performed. For patients with intestinal obstruction or overt small bowel bleeding, early surgical consultation should be considered.     

Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in adults and adolescents—a life-threatening disease: analysis of 133 cases from a single center

ABSTRACT

Objectives: Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis is the most common type of infection-associated HLH. Previous studies were focused on pediatric EBV-HLH patients, therefore there lack of adult data.

Method: We performed a retrospective analysis of 133 EBV-HLH patients (≥14 years old) in Beijing Friendship Hospital from March 2009 to April 2016 to evaluate the clinical manifestation and the effects and prognosis of existing regimens of EBV-HLH in adult and adolescents.

Results: Of these patients, 91 male and 42 female cases had a median age of 26 (14–77) years. EBV-DNA load on admission was at a median of 6.6E?+?05?IU/ml. The one-year mortality of these patients was 78%. 112 patients received the HLH-94/04 regimen as the initial treatment, 52 patients (46.43%) had response. Of the 6 patients who received the L-DEP regimen as the initial treatment, 5 patients (83.33%) had response. The rest 15 patients received initial treatment without etoposide, 5 cases achieved PR. 69 refractory or relapsed patients received DEP or L-DEP regimen, 55 (79.71%) cases had response. In addition, who received the L-DEP regimen, with the overall response rate significantly higher than the DEP regimen (88.37% VS 65.38%, P?=?0.031). 36 out of 133 EBV-HLH patients eventually received allo-HSCT, with the overall survival rate of 52.78%. In summary, EBV-HLH is a highly lethal disease.

Conclusion: DEP/L-DEP was a good salvage treatment. L-DEP might be a more effective first-line initial regimen than HLH-94/04 regimen for EBV-HLH. Finally, allo-HSCT is an effective radical treatment for EBV-HLH.     

Surgical strategies for chronic pancreatitis in a 1,327- patient Scandinavian Baltic pancreatic Club (SBPC) register

BackgroundChronic pancreatitis (CP) may cause intermittent or continuous pain and complications requiring invasive interventions. No specific recommendations for surgical interventions have been presented. Our aim was to determine the surgical treatment strategies for the treatment of CP in the Scandinavian and Baltic countries.MethodsThis multi-centre cross sectional study included 1327 CP patients from eight centres. The data was gathered from the Scandinavian Baltic Pancreatic Club (SBPC) database. Patients who underwent pancreatic surgery were analysed. The baseline CP population from the eight centres was used as a reference. The information registered included comorbidities, pancreatic function, previous interventions, time and type of surgery and the EORTC-30 quality of life (QOL) questionnaire.ResultsOverall, 95/1327 (7%) patients underwent pancreatic surgery. Fifty-one (54%) of these underwent pancreatic surgery for chronic pain (PSCP) and formed the final study group. Median follow-up time was two (range 0–8) years after surgery and seven (1–46) years after diagnosis. The most common surgical procedures were pancreatic resection combined with drainage (54%) followed by pancreatic resections (32%) and drainage procedures (14%). Postoperatively, 47% of the patients were pain free with or without pain medication while 16% had chronic pain episodes, this did not differ from the base CP population. In QOL questionnaires, PSCP patients reported the same QOL but worse social functioning and more symptoms compared to the CP population.ConclusionsPancreatic surgery for CP is rare: surgical procedures were performed on only 7% of the CP patients in the SBPC database. In half of the patients the indication was pain. Most of these patients underwent endoscopic procedures before surgery. Half of the patients reported being pain-free after surgery.     

Extracorporeal shock wave lithotripsy for pancreatic duct stones: an observational study

Abstract

Introduction: Previous studies suggest that fragmentation of pancreatic duct stones (PDS) using extracorporeal shock wave lithotripsy (ESWL) is associated with pain relief. However, the treatment may not be effective in certain subgroups.

Aim: To evaluate predictors of pain relief after ESWL in patients with chronic pancreatitis and PDS.

Methods: Retrospective study including patients with chronic pancreatitis undergoing ESWL for painful PDS. Analgesic use before and after the ESWL procedure was registered. We defined adequate pain relief after ESWL as ‘pain-free without analgesics or with use of weak analgesics as needed’. The study was approved by the Danish Data Protection Agency (approval number: AHH-2017-048).

Results: We included 81 patients (median age 58 years; 63% men; 68% alcoholic pancreatitis). Patients underwent one to seven ESWL procedures (mean 1.7). A concurrent ERCP was performed in 17%. All patients used analgesics before the ESWL procedure (68 used opioids). After ESWL, 43 still used opioids. Thirty-two patients achieved adequate pain relief. Univariable regression analysis showed that older age predicted adequate pain relief (OR 1.09;1.03–1.16; p?=?.002) as did location of the stone in the head or neck (OR 2.59;1.04–6.45; p?=?.041). In multivariable analysis, we found that the only two predictors of adequate pain relief were age (p?=?.002) and the location of the stones (p?=?.039).

Conclusion: After the ESWL, about four out of ten patients are pain-free without medication or able to manage their pain with weak analgesics. Age and the location of the stones may be considered when evaluating if patients are eligible for referral to ESWL.     

Localized intrahepatic IgG4-related sclerosing cholangitis (IgG4-SC) as an additional type of IgG4-SC: a systematic analysis of 12 cases

Objectives: IgG4-related sclerosing cholangitis (IgG4-SC), a recently defined disease entity, has been classified into four types based on the stricture regions revealed by cholangiography. However, localized intrahepatic IgG4-SC is not included into the classification. This study aimed to analyze and characterize localized intrahepatic IgG4-SC and justify the inclusion of this type into the classification.

Methods: PubMed and Embase were searched for studies published from March 2001 to June 2017 reporting localized intrahepatic IgG4-SC. Data were obtained and analyzed from the included articles.

Results: Twelve cases of localized intrahepatic IgG4-SC were included. All patients were adults with the median age of 73 years (range 46–78), and had a male preponderance (88.9%). The most common clinical presentation was obstructive jaundice (50%), abdominal pain (25%) and absence of symptoms (25%). On imaging and macroscopically, localized intrahepatic IgG4-SC presented with three subtypes, i.e., mass-forming (n?=?6, 50%), stricture (n?=?5, 41.7%) and periductal infiltrating (n?=?1, 8.3%) subtypes. Among the eight cases with diagnoses reported, six patients were misdiagnosed as intrahepatic cholangiocarcinoma; one was diagnosed as hepatic mass and one as IgG4-SC before biopsy or operation. Information on treatment was available on 10 cases; eight underwent surgical resection, one received steroid treatment alone and one underwent endoscopic biliary drainage. No relapse was noted in patients with surgical resection during a period of followed up.

Conclusions: The localized intrahepatic IgG4-SC presents with mass-forming, stricture and periductal infiltrating subtypes, and should be recognized as an additional type of IgG4-SC according to the cholangiographic classification or anatomic site.     

Long-term follow-up of neoplastic pancreatic cysts without high-risk stigmata: how often do we change treatment strategy because of malignant transformation?

*Objective: Patients with potentially premalignant neoplastic pancreatic cysts without high-risk stigmata usually enter a surveillance program. Data on outcomes of such surveillance programs are scarce. We aimed to evaluate the resection rate and malignancy rate during follow-up.

Material and methods: From our prospective database (2006–2015) of patients with pancreatic cysts, we analyzed patients with pancreatic cysts without high-risk stigmata with at least six months follow-up.

Results: In total, 146 patients were followed for a median of 29 months (IQR 13.5–50 months). In 124 patients (84.9%), no changes in clinical or imaging characteristics occurred during follow-up. Thirteen patients (8.9%) developed an indication for surgery after a median follow-up of 25 months (IQR 12–42 months). Two patients did not undergo surgery because of comorbidity, 11 patients (7.5%) underwent resection. Indications for surgery were symptoms (n?=?2), development of a pancreatic mass (n?=?1), a new nodule (n?=?2), thickened cyst wall (n?=?1), pancreatic duct dilation (n?=?3), and/or suspicion of mucinous cystic neoplasm (MCN) (n?=?3). Postoperative histology showed one pancreatic malignancy not originating from the cyst, three mixed type-intraductal papillary mucinous neoplasm (IPMN), one side branch-IPMN, two MCN, one neuroendocrine tumor, one serous cystadenoma, one inflammatory cyst, and one lymphangioma. The highest grade of cyst dysplasia was borderline dysplasia.

Conclusions: Most neoplastic pancreatic cysts without high-risk stigmata at initial presentation show no substantial change during 1–4-year follow-up. Only 7.5% of patients underwent surgery and less than 1% of patients developed pancreatic malignancy. This indicates that additional markers are needed to tailor treatment of pancreatic cysts.     

Tolerability profile of thiopurines in inflammatory bowel disease: a prospective experience

Objectives: The occurrence of thiopurine-related adverse events (AEs) may complicate the management of patients with inflammatory bowel disease (IBD). We aimed to evaluate the tolerability of thiopurines in a current IBD setting.

Materials and methods: All consecutive patients who started a treatment with azathioprine (AZA) from January 2010 to March 2016 were entered in a prospectively maintained database, and the AEs which led to the permanent discontinuation of the drug were reported.

Results: Two hundred and fifty three patients were included. Median total follow-up was 32 months (range: 0.2–75 months). At the end of the study, AZA was discontinued in 160 patients (63.2%). The main reason leading to drug withdrawal was the occurrence of AEs (109/160 patients [68.1%]; cumulative incidence among the entire cohort: 43.1%). Overall, the most frequent AEs leading to treatment withdrawal were nausea (31/253 patients, 12.3%) and subjective symptoms, i.e., poorly defined side effects such as fatigue, headache and muscle pain (20/253 patients, 7.9%). Among the 109 AZA-intolerant patients, a switch to 6-mercaptopurine (6-MP) was performed in 44 cases (40.4%). At the end of follow-up, 6-MP was discontinued in 35/44 patients (79.5%), mostly due to AEs (29/35 patients, 82.8%). Azathioprine-induced hepatic and pancreatic toxicity was associated with male gender (p?=?.01 and p?=?.03, respectively), and occurrence of nausea with Crohn’s disease (p?=?.04).

Conclusions: Our real-life prospective cohort showed the higher cumulative incidence of thiopurine withdrawal due to AEs reported to date. Switching from AZA to 6-MP was often ineffective.