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Endoscopic mucosal resection and endoscopic submucosal dissection in the treatment of sporadic nonampullary duodenal adenomatous polyps

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World Journal of Gastrointestinal Endoscopy 2015年第7期7卷 720-727页

作者： Joana Marques Francisco Baldaque-Silva Pedro Pereira urban arnelo Naohisa Yahagi Guilherme Macedo Faculty of Medicine University of Porto Gastrocentrum Karolinska University Hospital Karolinska Institutet Gastroenterology Department Hospital Sao Joao Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institutet and Centre for Digestive Diseases Karolinska University Hospital Division of Research and Development for Minimally Invasive Treatment Cancer Center School of Medicine Keio University

Although uncommon, sporadic nonampullary duodenal adenomas have a growing detection due to the widespread of endoscopy. Endoscopic therapy is being increasingly used for these lesions, since surgery, considered the standard treatment, carries significant morbidity and mortality. However, the knowledge about its risks and benefits is limited, which contributes to the current absence of standardized recommendations. This review aims to discuss the efficacy and safety of endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD) in the treatment of these lesions. A literature review was performed, using the Pubmed database with the query: "(duodenum or duodenal)(endoscopy or endoscopic) adenoma resection", in the human species and in English. Of the 189 retrieved articles, and after reading their abstracts, 19 were selected due to their scientific interest. The analysis of their references, led to the inclusion of 23 more articles for their relevance in this subject. The increased use of EMR in the duodenum has shown good results with complete resection rates exceeding 80% and low complication risk(delayed bleeding in less than 12% of the procedures). Although rarely used in the duodenum, ESD achieves close to 100% complete resection rates, but is associated with perforation and bleeding risk in up to one third of the cases. Even though literature is insufficient to draw definitive conclusions, studies suggest that EMR and ESD are valid options for the treatment of nonampullary adenomas. Thus, strategies to improve these techniques, and consequently increase the effectiveness and safety of the resection of these lesions, should be developed.

关键词： Polyps Duodenum Adenoma Resection Endoscopy

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Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury

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World Journal of Gastroenterology 2013年第36期19卷 6026-6034页

作者： Fredrik Swahn Sara Regnér Lars Enochsson Lars Lundell Johan Permert Magnus Nilsson Henrik Thorlacius urban arnelo Division of Surgery Department of Clinical Science Intervention and TechnologyKarolinska Institutet Department of Surgical Gastroenterology Karolinska University Hospital Department of Clinical Science Lund University Skne University Hospital Department of Surgery Skne University Hospital

AIM:To examine whether rendezvous endoscopic retrograde cholangiopancreatography(ERCP)is associated with less pancreatic damage,measured as leakage of proenzymes,than conventional ***:Patients(n=122)with symptomatic gallstone disease,intact papilla and no ongoing inflammation,were prospectively enrolled in this case-controldesigned ***-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones(CBDS),rendezvous ERCP was performed intraoperatively(n=40).Patients with a negative cholangiogram constituted the control group(n=41).Another 41 patients with CBDS,not subjected to surgery,underwent conventional *** proenzymes,procarboxypeptidase B and trypsinogen-2 levels in plasma,were analysed at 0,4,8 and 24 *** proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent *** amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer’s *** samples were blinded at ***:Post ERCP pancreatitis(PEP)occurred in3/41(7%)of the patients cannulated with conventional ERCP and none in the rendezvous *** serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4-and 8-h samples(P=0.0015;P=0.03),procarboxypeptidase B in the4-and 8-h samples(P<0.0001;P<0.0001)and trypsinogen-2 in the 24-hour samples(P=0.03).No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone(control group).Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and ***:Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation ***,l

关键词： Common bile duct stones Procarboxypeptidase B Trypsinogen-2 Pancreatic amylase Intraoperative endoscopic retrograde cholangiopancreatography

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Losartan to prevent hyperenzymemia after endoscopic retrograde cholangiopan-creatography: A randomized clinical trial

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World Journal of Gastrointestinal Endoscopy 2012年第11期4卷 506-512页

作者： Tomas Sjberg Bexelius John Blomberg Hans-Olof Hkansson Peter Mller Carl-Eric Nordgren urban arnelo Jesper Lagergren Mats Lindblad Upper Gastrointestinal Research Department of Molecular Medicine and Surgery Karolinska Institutet 176 70 Stockholm Sweden Department of Surgery Gastro Center Karolinska University Hospital Department of Surgery Kalmar County Hospital Department of Clinical Science Intervention and Technology Karolinska Institutet 176 70 Stockholm Sweden

AIM: To study if the angiotensin II receptor blockers (ARB) losartan counteracts pancreatic hyperenzymemia as measured 24 h after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A triple-blind and placebo-controlled randomized clinical trial was performed at two Swedish hospitals in 2006-2008. Patients over 18 years of age undergoing ERCP, excluding those with current pancreatitis, current use of ARB, and severe disease, such as sepsis, liver and renal failure. One oral dose of 50 mg losartan or placebo was given one hour before ERCP. The relative risk of hyperenzymemia 24 h after ERCP was estimated using multivariable logistic regression, and expressed as odds ratio with 95% confidence intervals (CIs), including adjustment for potential remaining confounding. RESULTS: Among 76 participating patients, 38 were randomized to the losartan and the placebo group, respectively. The incidence rates of hyperenzymemia and acute pancreatitis among all 76 participating patients were 21% and 12%, respectively. Hyperenzymemia was detected in 9 and 7 patients in the losartan and placebo group, respectively. There were no major differences between the comparison groups regarding cannulation difficulty, findings, or proportion of patients requiring drainage of the bile ducts. There were, however, more pancreatic duct injections, a greater extent of pancreatography, and more biliary sphincterotomies in the losartan group than in the placebo group. Losartan was not associated with risk of hyperenzymemia compared to the placebo group after multi-varible logistic regression analysis (odds ratio 1.6, 95%CI 0.3-7.8). CONCLUSION: In this randomized trial 50 mg losartan given orally had no prophylactic effect on development of hyperenzymemia after ERCP.

关键词： Renin-angiotensin system Pancreatitis Prophylaxis Placebo-controlled trial

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Methods and outcomes of screening for pancreatic adenocarcinoma in high-risk individuals

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World Journal of Gastrointestinal Endoscopy 2015年第9期7卷 833-842页

作者： Gabriele Capurso Marianna Signoretti Roberto Valente urban arnelo Matthias Lohr Jan-Werner Poley Gianfranco Delle Fave Marco Del Chiaro Digestive and Liver Disease Unit S.Andrea HospitalUniversity Sapienza Departments of Gastroenterology and Hepatology Erasmus MCUniversity Medical Center Pancreatic Surgery Unit Division of SurgeryCLINTECKarolinska Institutet at Karolinska University Hospital

Pancreatic ductal adenocarcinoma(PDAC) is a lethal neoplasia, for which secondary prevention(i.e., screening) is advisable for high-risk individuals with "familiar pancreatic cancer" and with other specific genetic syndromes(Peutz-Jeghers, p16, BRCA2, PALB and mismatch repair gene mutation carriers). There is limited evidence regarding the accuracy of screening tests, their acceptability, costs and availability, and agreement on whom to treat. Successful target of screening are small resectable PDAC, intraductal papillary mucinous neoplasms with high-grade dysplasia and advanced pancreatic intraepithelial neoplasia. Both magnetic resonance imaging(MRI) and endoscopic ultrasound(EUS) are employed for screening, and the overall yield for pre-malignant or malignant pancreatic lesions is of about 20% with EUS and 14% with MRI/magnetic resonance colangiopancreatography. EUS performs better for solid and MRI for cystic lesions. However, only 2% of these detected lesions can be considered a successful target, and there are insufficient data demonstrating that resection of benign or low grade lesions improves survival. Many patients in the published studies therefore seemed to have received an overtreatment by undergoing surgery. It is crucial to better stratify the risk of malignancy individually, and to better define optimal screening intervals and methods either with computerized tools or molecular biomarkers, possibly in large multicentre studies. At the moment, screening should be carefully performed within research protocols at experienced centres, offering involved individuals medical and psychological advice.

关键词： Endoscopic ultrasound Pancreatic cancer Screening High-risk individuals Magnetic resonance

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