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Background & Aims There is substantial interest in liquid biopsy approaches for cancer early detection among subjects at risk, using multi-marker panels. CA19-9 is an established circulating biomarker for pancreatic cancer; however, its relevance for pancreatic cancer early detection or for monitoring subjects at risk has not been established. Methods CA19-9 levels were assessed in blinded sera from 175 subjects collected up to 5 years before diagnosis of pancreatic cancer and from 875 matched controls from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. For comparison of performance, CA19-9 was assayed in blinded independent sets of samples collected at diagnosis from 129 subjects with resectable pancreatic cancer and 275 controls (100 healthy subjects; 50 with chronic pancreatitis; and 125 with noncancerous pancreatic cysts). The complementary value of 2 additional protein markers, TIMP1 and LRG1, was determined. Results In the PLCO cohort, levels of CA19-9 increased exponentially starting at 2 years before diagnosis with sensitivities reaching 60% at 99% specificity within 0 to 6 months before diagnosis for all cases and 50% at 99% specificity for cases diagnosed with early-stage disease. Performance was comparable for distinguishing newly diagnosed cases with resectable pancreatic cancer from healthy controls (64% sensitivity at 99% specificity). Comparison of resectable pancreatic cancer cases to subjects with chronic pancreatitis yielded 46% sensitivity at 99% specificity and for subjects with noncancerous cysts, 30% sensitivity at 99% specificity. For prediagnostic cases below cutoff value for CA19-9, the combination with LRG1 and TIMP1 yielded an increment of 13.2% in sensitivity at 99% specificity (P = .031) in identifying cases diagnosed within 1 year of blood collection. Conclusion CA19-9 can serve as an anchor marker for pancreatic cancer early detection applications.

Background & Aims It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. Methods We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. Results By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). Conclusions In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416 .

A 43 year old woman with a history of abdominal trauma from a motor vehicle accident three years prior to admission presented with increasing severe abdominal pain located in the epigastrium and left upper quadrant with radiation to the back, significant nausea, and intermittent vomiting. The pain was exacerbated by both eating and drinking. On physical examination she was afebrile with a soft abdomen that was tender to minimal palpation in the epigastric and left upper quadrant regions. Laboratory data was notable for normal amylase, lipase, liver function tests, white blood cell count, and hematocrit. The pain improved minimally with NPO status and intravenous fluids. Initial magnetic resonance imaging (MRI) of the pancreas before admission demonstrated pancreatitis involving the neck and body of the pancreas with peripancreatic fluid. A follow-up MRI was performed (Figures A and ​andB).B). Endoscopic ultrasound subsequently confirmed the presence of multiloculated cysts adjacent to the neck-body of the pancreas with the largest pocket measuring 2.5 by 1.6 cm and normal-appearing adjacent pancreatic parenchyma and pancreatic duct (Figure C). Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) yielded this fluid (Figure D). What is the diagnosis? Figure A Figure B Figure C Figure D EUS-FNA revealed milky fluid with carcinoembryonic antigen 1.8 ng/mL, amylase 307 U/L, lipase 382 U/L, and triglyceride 2972 mg/dL. During subtotal pancreatectomy, a cystic mass was identified involving the pancreatic body on the left with a normal tail to the right in the image (Figure E). Heavy cream delivered via a nasogastric tube in the duodenum produced milky fluid seen leaking from lymphatics and the cyst cavity. Most commonly presenting in children, lymphangiomas are rare benign neoplasms that arise from obstructed lymphatic vessels, which progressively dilate cystically due to detachment of lymphatic tissue during embryologic development.1 First described by Koch in 1913, pancreatic lymphangiomas are exceedingly rare, representing less than 1% of all lymphangiomas and 0.2% of all pancreatic lesions.2 Histology demonstrates fat with dilated thin walled lymphatic spaces lined by endothelium without atypia (Figure F) and pancreas infiltrated by these dilated lymphatic spaces (Figure G). Abdominal trauma, inflammation, surgery, and radiation therapy have all been associated with lymphatic channel obstruction leading to vessel dilation and potentially lymphangioma. Usually asymptomatic, patients with pancreatic lymphangioma may present with abdominal pain, nausea, weight loss, palpable abdominal mass, hemorrhage, hydronephrosis, or infection. CT and MRI typically demonstrate a multicystic, well-defined, encapsulated lesion with thin septa and a fatty component.3 MRI of our patient demonstrated septated, well-defined peripancreatic fluid with lymphangioma infiltrating pancreatic parenchyma in the neck and body. EUS-FNA can help diagnose lymphangiomas, and while the classic milky white fluid is not always encountered, this appearance combined with an elevated triglyceride level is diagnostic of lymphangioma.1 After EUS-FNA, our patient reported mild improvement in her abdominal pain although she continued with poor nutrition due to postprandial pain. While complete surgical resection offers definitive therapy for pancreatic lymphangiomas, it is reserved for symptomatic patients, and recurrence can occur with incomplete excision. Following resection, our patient resumed a normal diet without abdominal pain. Figure E Figure F Figure G

Purpose: Traditionally patients with classic reflux symptoms but minimally abnormal esophageal pH studies have not been considered ideal surgical candidates. Endolummal gastroplication (ELGP) has been shown to improve clinical outcome in patients with gastroesophageal disease (GERD) but it remains unclear if equally impressive improvements occur in this patient population. The aim of this study is to evaluate symptomatic outcome after ELGP in patients with reflux symptoms and minimally abnormal pH studies. Methods: Patients with GERD and minimally abnormal DeMeester scores defined as less than or equal to 30 were included. Between July 2001-July 2002, 23 patients who underwent ELGP for GERD met this criterion. All ELGPs were performed with 2 or 3 plications placed 1 to 2 cm below the gastroesophageal junction. Follow-up data included weight, BMI, heartburn frequency score (HFS), heartburn severity (HSV), heartburn symptom score (HSS), regurgitation frequency (RFS), and medication use; in 3 patients manometries, pH studies, and upper endoscopy findings were obtained at variable intervals after ELGP. Results: For the 23 patients, average age was 51 with 11 men, 12 women and average BMI 28. Nine of 23 patients had a history of previous surgical fundoplication. Only 1 patient was not on medication'before or after the ELGP. On average at baseline patients reported only a 36% improvement in symptoms on medications. Average baseline lower esophageal sphincter pressure (LESP) was low at 17.4 +/-8.6mmHg with DeMeester scores of 18.5+/-9.0. Mean follow up was 4.3 months. For all symptom scores, improvement occurred POst-ELGP (all p