Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 14, 2019; 25(18): 2217-2228
Published online May 14, 2019. doi: 10.3748/wjg.v25.i18.2217
Role of abdominal ultrasound for the surveillance follow-up of pancreatic cystic neoplasms: a cost-effective safe alternative to the routine use of magnetic resonance imaging
Luca Morelli, Simone Guadagni, Valerio Borrelli, Roberta Pisano, Gregorio Di Franco, Matteo Palmeri, Niccolò Furbetta, Dario Gambaccini, Santino Marchi, Piero Boraschi, Luca Bastiani, Alessandro Campatelli, Franco Mosca, Giulio Di Candio
Luca Morelli, Simone Guadagni, Gregorio Di Franco, Matteo Palmeri, Niccolò Furbetta, Giulio Di Candio, General Surgery Unit, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Pisa 56124, Italy
Luca Morelli, Franco Mosca, EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa 56124, Italy
Valerio Borrelli, Roberta Pisano, Alessandro Campatelli, Diagnostic and Interventional Ultrasound in Transplants Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
Dario Gambaccini, Santino Marchi, Gastroenterology Unit, University of Pisa, Pisa 56124, Italy
Piero Boraschi, 2nd Radiology Unit, Department of Diagnostic Imaging, Azienda Ospedaliero-Universitaria Pisana, Pisa 56124, Italy
Luca Bastiani, Institute of Clinical Physiology, National Council of Research, Pisa 56124, Italy
Author contributions: Morelli L, Guadagni S, Di Franco G, Palmeri M, Furbetta N, Marchi S, Boraschi P, Mosca F and Di Candio G designed research; Morelli L, Guadagni S, Borrelli V, Pisano R, Furbetta N, Gambaccini D, Bastiani L, Campatelli A and Di Candio G performed research; Morelli L, Palmeri M, Di Franco G and Bastiani L analyzed data; Morelli L, Guadagni S, Borrelli V, Pisano R, Di Franco G, Palmeri M, Furbetta N, Gambaccini D, Marchi S, Boraschi P, Campatelli A, Mosca F and Di Candio G wrote the paper.
Institutional review board statement: The study was approved by Ethics committee of “Area Vasta Nord Ovest (CEAVNO)”.
Informed consent statement: All patients signed an informed consent to authorize the scientific use of the collected data.
Conflict-of-interest statement: No conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Luca Morelli, MD, FACS, Associate Professor, General Surgery Unit, Department of Surgery, Translation and New Technologies in Medicine, University of Pisa, Via Paradisa 2, Pisa 56124, Italy.
Telephone: +39-50-995470 Fax: +39-50-996985
Received: December 13, 2018
Peer-review started: December 13, 2018
First decision: December 28, 2018
Revised: January 27, 2019
Accepted: January 28, 2019
Article in press: January 28, 2019
Published online: May 14, 2019
Research background

The current international guidelines only consider magnetic resonance imaging (MRI) for the follow-up of patients with pancreatic cystic neoplasms (PCN). Given the great number of patients with PCN that have to be followed-up due to the inherent risk of malignant progression, the use of abdominal ultrasound (US) might be a quick, easily accessible and cost-saving imaging modality. Recent publications have evaluated the role of US in monitoring PCN, but none have proposed a safe alternative follow-up surveillance based on US with restricted MRI use.

Research motivation

We performed this study in order to evaluate the safety and cost-efficacy of US as a diagnostic tool to simplify the follow-up of selected patients with low risk pancreatic cystic neoplasms.

Research objectives

The objectives of this study were: (1) to evaluate the safety of the use of US in the surveillance of patients with good acoustic window and low-risk pancreatic cystic neoplasms; and (2) to propose an alternative follow-up protocol that reduces the cost with respect to the cost incurred by current international guidelines.

Research methods

We retrospectively evaluated the safety and costs of a follow-up surveillance for patients with low-risk PCN, performed with 6 monthly abdominal US for the first year, and then annually and with recourse to MRI scans performed every 2 years, or for confirmation of suspicious US findings.

Research results

Between January 2012 and January 2017, we followed 200 patients with a specific protocol that included abdominal US scans for pancreatic cystic neoplasms. During a follow-up period of 25.1 ± 18.2 mo, MRI identified evolution of the lesions not detected by US in only 11 patients (5.5%). However, MRI every 6 mo would not have changed patient management in any case. The mean cost of surveillance for each patient based on theoretical application MRI surveillance (recommended by international guidelines) within the group of patients included in the study would have incurred costs of 1158.9 ± 798.6 €, compared to the surveillance costs incurred by the proposed US-restricted MRI protocol of 366.4 ± 348.7 € (P < 0.0001).

Research conclusion

Abdominal US seems to provide a cost-effective surveillance that reduces the frequency of MRI scans without affecting patient outcome. This is important in reducing the financial burden on hospital healthcare, aside from reducing the examination time and MRI-related issues and side effects. For patients with PCN, we have proposed a follow-up surveillance that includes abdominal US, and demonstrated that it is safe and complementary to MRI. In addition, it effectively delays and reduces the number of MRI scans, thereby reducing the cost of surveillance.

Research perspectives

The results of the present study need to be confirmed by a comparative prospective randomized trial with both clinical (long-term patient outcome safety) and health economic primary endpoints.