Nadeem Tehami

Endoscopic ultrasound-guided portal pressure gradient and liver biopsy to determine the need for isolated kidney transplantation versus combined liver-kidney transplantation

Objective Most studies have assessed the impact of elevated serum amylase levels in clinical practice, but only a few have investigated the significance of low serum amylase. We therefore, aimed to review the literature to understand the conditions associated with low serum amylase and its clinical relevance. Method This systematic review was performed in accordance with the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on Medline and Embase databases until November 2022. After identifying relevant titles, abstracts were read and data of eligible articles retrieved. The conditions associated with low serum amylase were evaluated. The quality of the studies was assessed using the Newcastle-Ottawa Score. Results Our search strategy identified 19 studies including a total of 15 097 patients for systematic review. All the studies were observational including two studies which used secretin-induced test. The main conditions associated with low serum amylase were diabetes mellitus (n=9), metabolic syndrome (n=3), chronic pancreatitis (CP) (n=3), non-alcoholic fatty liver disease (n=2) and obesity (n=1). Low serum amylase showed a high specificity (94%) with low sensitivity (38.7%–59%) in diagnosing chronic pancreatitis. Conclusion This systematic review revealed a unique insight into the relevance of low serum amylase in clinical practice. Low serum amylase can be a useful adjunct test in the assessment of patients with CP, pancreatic exocrine insufficiency, diabetes mellitus and metabolic syndrome.

Role of endoscopic ultrasound in the characterization of solid pseudopapillary neoplasm of the pancreas

The Journal of Cancer Metastasis and Treatment is an open access journal focused on cancer metastasis and treatment, including the occurrence, development, progression, metastasis, and treatment of oncologic disease. It covers basic, translational and clinical research related to cancer cell biology, genomics, precision medicine, oncology internal medicine, radiotherapy and radiology, obstetrics and gynecology, pediatrics, surgery, hematology, neurooncology, etc.

We congratulate King et al. for their recent paper and for coining the term “post-endoscopic ultrasound pancreatic cancer (PEPC)” [1]. We would however like to draw your attention to a few observations, as elaborated below. The authors propose PEPC to be analogous to post-colonoscopy colorectal cancer (PCCRC). This analogy may not be accurate for two main reasons. Firstly, endoscopic ultrasound (EUS) is not used for population-based screening in average risk individuals. Secondly, in individuals with a clinical suspicion of carcinoma of the pancreas, EUS is always supported by multimodality evaluation, including tissue acquisition. EUS is a two-dimensional imaging modality and augments cross-sectional imaging, mostly when tissue is being obtained (i. e. to confirm the diagnosis). Therefore, pancreatic cancer that was missed by the initial evaluation should not be considered to be a failure of EUS, but a failure of multimodality evaluation to detect the lesion. This is in contrast to colonoscopy, which, as a standalone procedure, is considered sufficient to rule out carcinoma of the colon. The authors assume that, if a diagnosis of carcinoma of the pancreas was coded within 6 months of the EUS, the diagnosis was made by EUS; if made between 6 and 18 months, the diagnosis was missed by EUS. We believe this assumption is completely arbitrary and not firmly grounded in science. With existing guidelines for pancreatic cancer screening recommending yearly screening when there are no concerning lesions on the index evaluation and an interval as short as 3 months for high risk lesions [2], the classifications proposed by the authors do not correspond with the available literature. We value the contributions of the authors in improving key performance measures in endoscopy with respect to missed cancer diagnosis. We, however, request that EUS assessments have to be considered in conjunction with other imaging modalities in the diagnosis of carcinoma of the pancreas. Article published online: 20 December 2022 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background: Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom. Methods: Consecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records. Results: Twenty five patients (15 males) with a median age of 63 years old (range 29–80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p < 0.01). Adverse events occurred in 2/25 patients (8%), both due to stent maldeployment necessitating endoscopic closure of the gastric defect with clips. Long-term follow-up data were available for 21 of 23 patients and the re-intervention rate was 4.8% (1/21) over a median follow-up period of 162 (range 5–474) days. Conclusion: EUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.

Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.