Assessment of morbidity and mortality associated with endoscopic ultrasound-guided fine-needle aspiration for pancreatic cystic lesions: A systematic review and meta-analysis

Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

This Technical and Technology Review from the European Society of Gastrointestinal Endoscopy (ESGE) represents an update of the previous document on the technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including the available types of needle, technical aspects of tissue sampling, new devices, and specimen handling and processing. Among the most important new recommendations are:ESGE recommends end-cutting fine-needle biopsy (FNB) needles over reverse-bevel FNB or fine-needle aspiration (FNA) needles for tissue sampling of solid pancreatic lesions; FNA may still have a role when rapid on-site evaluation (ROSE) is available.ESGE recommends EUS-FNB or mucosal incision-assisted biopsy (MIAB) equally for tissue sampling of subepithelial lesions ≥20 mm in size. MIAB could represent the first choice for smaller lesions (<20 mm) if proper expertise is available.ESGE does not recommend the use of antibiotic prophylaxis before EUS-guided tissue sampling of solid masses and EUS-FNA of pancreatic cystic lesions.

Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Plasma treatment can efficiently increase the attachment of pancreatic circulatory tumor cells to the surface

Pancreatic cancer ranks as the fourth most common cause of cancer-related fatalities globally, with a notably low 5-year relative survival rate. We need to immediately develop fast, dependable, and noninvasive diagnostic techniques that can accurately identify pancreatic cancer at an early stage. The research project created a straightforward but effective method for detecting and increasing the amount of tumor cells that could bind to polystyrene (PS) well plates. To significantly improve the adhesion of the pancreatic cancer cell line PANC-1 on PS well plates, a 5-min exposure to high-power oxygen plasma was implemented. This treatment caused a significant increase in surface energy and roughness. Surface characterization was assessed by utilizing an atomic force microscope and X-ray photoelectron spectroscopy. Water contact angle measurement is used to assess the level of wettability present on the treated surface. To determine how well the circulatory tumor cells (CTCs) model adheres to a plasma-treated surface (PTS), appropriate amounts of mCherry-labeled PANC-1 cells are mixed into a sample of blood cells to mimic clinical conditions. After applying plasma treatment, the experiment achieved a 96% success rate in binding at 2 h, specifically for the PANC-1 cell type. Moreover, the platform demonstrated a considerable ability to attach to cancerous cells compared to non-cancerous cells found in blood. To summarize, this study has shown that non-thermal plasma treatment could be a novel and efficient method for the better adhesion of pancreatic cancer cells, with the benefits of being cost-effective and quick. It is necessary for additional research to be conducted to confirm the clinical efficacy of the method.

Endoscopic Ultrasound armamentarium for precise and early diagnosis of biliopancreatic lesions

The diagnostic paradigm for biliopancreatic lesions has been revolutionized by continuous advancements in endoscopic ultrasound (EUS) technologies and techniques. This review examines the expanding diagnostic toolkit available to clinicians, emphasizing innovations that have significantly enhanced precision and early detection capabilities. One of the most transformative advancements is the development of fine-needle biopsy (FNB) needles. Modern designs, including Franseen, and fork-tip configurations, have optimized tissue sampling, achieving diagnostic accuracies exceeding 90 % while minimizing the number of needle passes required. These innovations facilitate the acquisition of high-quality histological specimens suitable for comprehensive molecular profiling, paving the way for personalized therapeutic approaches. Concurrent advancements in sampling techniques have bolstered these needle design improvements. The fanning technique has been particularly effective, increasing diagnostic yields from 71 % to 88 %. Wet suction methods preserve tissue integrity better than traditional approaches, while standardized protocols for needle passes enhance procedural efficiency. For specimen evaluation, Rapid On-Site Evaluation (ROSE) offers 93 % sensitivity, while alternatives like Macroscopic On-Site Evaluation (MOSE) provide comparable accuracy while reducing dependency on specialized personnel and resources. Image enhancement technologies have markedly improved the ability to characterize lesions. Contrast Harmonic EUS (CH-EUS) is particularly effective in differentiating pancreatic cancer from other solid lesions, with meta-analyses confirming sensitivity and specificity of 94 % and 89 %, respectively. Its ability to detect lesions as small as 15 mm makes it invaluable for early diagnosis. In cystic lesions, CH-EUS excels in identifying malignant mural nodules, with diagnostic accuracies reaching 96 %. The integration of elastography and advanced digital imaging technologies has further expanded diagnostic capabilities. Strain elastography provides qualitative insights into tissue characteristics, while shear wave elastography offers quantitative measurements of stiffness, adding diagnostic precision. Similarly, technologies like detective flow imaging match the accuracy of contrast-enhanced techniques in pancreatic cancer detection and enhance vascular assessment. For cystic lesions, diagnostics have progressed beyond traditional fluid analysis. Techniques such as through-the-needle biopsy (TTNB) have improved diagnostic yields to 74 %, albeit with a modest risk of complications. Incorporating molecular markers and next-generation sequencing allows differentiation between cystic lesion subtypes and more accurate assessment of malignant potential. This array of diagnostic tools offers unprecedented potential for early and precise diagnosis of biliopancreatic lesions. Integrating these innovations into clinical practice requires careful consideration of their strengths and limitations. Future research should aim to standardize protocols and establish evidence-based algorithms for their combined use, with the ultimate goal of improving patient outcomes through earlier detection and tailored management of biliopancreatic pathologies.

Pancreatic Mass Requiring a Modified Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE) Procedure for Endoscopic Ultrasound (EUS) Evaluation

Pancreatic cancer is established as being a leading cause of cancer-related mortality within the U.S. annually. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) has been shown to be more sensitive and specific when compared to computed tomography (CT) imaging for the evaluation of pancreatic masses. Patients with altered anatomy after a Roux-en-Y gastric bypass (RYGB) procedure necessitated the development of additional techniques for biopsy and evaluation of gastrointestinal structures, such as the endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedure. The ERCP procedure was enhanced with the internal EDGE, utilizing the lumen-apposing covered metal stent (LAMS) to create a gastrogastric fistula for instrumentation to pass through in order to access the excluded gastric region without any transcutaneous hardware. The case detailed here required the utilization of a modified EDGE procedure to allow for EUS-FNA of a pancreatic mass in a patient with RYBG anatomy. This is a presentation of a modified internal EDGE procedure in a 70-year-old male with a past medical history of RYGB and colon cancer and presented with a large pancreatic mass that was unable to be sampled by a transcutaneous CT-guided biopsy or EUS alone due to his altered anatomy. Due to the RYGB anatomy of the patient, a modified internal EDGE procedure was conducted in two stages with a LAMS, followed by a transgastric EUS-FNA of the pancreatic mass after access to the isolated gastric limb was achieved. A definitive diagnosis of pancreatic adenocarcinoma was then able to be made based on this biopsy. The benefits of using EUS for pancreatic cancer evaluation are well-established in the literature with a sensitivity of 85-92% and specificity of 96-98% when evaluating pancreatic cancers and using FNA. The pairing of this imaging modality with biopsy capability is what ultimately allowed for a viable sample to be obtained in this case. Due to the limited available literature documenting the utility of an EDGE procedure in obtaining viable samples for oncologic evaluation, this case is a valuable addition as it demonstrates the utility of EDGE with EUS-FNA for difficult biopsy sites related to post-Roux-en-Y anatomy where more conventional measures failed. The authors believe education on the utility of EDGE procedures should be promoted and offered when appropriate and available.

Endoscopic Ultrasound-Guided Pancreatic Tissue Sampling: Lesion Assessment, Needles, and Techniques

Endoscopic ultrasound (EUS)-guided tissue sampling includes the techniques of fine needle aspiration (FNA) and fine needle biopsy (FNB), and both procedures have revolutionized specimen collection from the gastrointestinal tract, especially from remote/inaccessible organs. EUS-FNB has replaced FNA as the procedure of choice for tissue acquisition in solid pancreatic lesions (SPLs) across various society guidelines. FNB specimens provide a larger histological tissue core (preserving tissue architecture) with fewer needle passes, and this is extremely relevant in today's era of precision and personalized molecular medicine. Innovations in needle tip design are constantly under development to maximize diagnostic accuracy by enhancing histological sampling capabilities. But, apart from the basic framework of the needle, various other factors play a role that influence diagnostic outcomes, namely, sampling techniques (fanning, aspiration or suction, and number of passes), collection methods, on-site evaluation (rapid, macroscopic, or visual), and specimen processing. The choice taken depends strongly on the endoscopist's preference, available resources at the disposal, and procedure objectives. Hence, in this review, we explicate in detail the concepts and available literature at our disposal on the topic of EUS-guided pancreatic tissue sampling to best guide any practicing gastroenterologist/endoscopist in a not-to-ideal set-up, which EUS-guided tissue acquisition technique is the "best" for their case to augment their diagnostic outcomes.

Risk of Pancreatitis After Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is frequently used to risk-stratify pancreatic cystic lesions (PCLs). Rising PCL incidence and developments in tissue acquisition and specimen analysis necessitate updated appraisal of EUS-FNA safety, particularly the risk of postprocedure pancreatitis, the most common EUS-FNA-related adverse event. Our systematic review aims to accurately quantify the risk of EUS-FNA-related pancreatitis to best inform decisions regarding EUS-FNA's optimal role in PCL workup.

METHODS

We performed systematic searches in 4 databases from inception to April 2024 for original English-language studies investigating EUS-FNA-related pancreatitis. We extracted data on demographics and EUS-FNA-related pancreatitis risk, severity, and risk factors. These were meta-analyzed through the DerSimonian Laird Method using a random-effects model. Meta-regression of pancreatitis risk was performed to delineate associations with clinical and procedural characteristics.

RESULTS

Sixty-four studies comprised 8,086 patients and reported 110 EUS-FNA-related pancreatitis events. Pooled risk of EUS-FNA-related pancreatitis was 1.4% (95% confidence intervals, -0.8% to 3.5%; I2 = 0.00), which was predominantly of mild severity (67%) and uniformly nonfatal. Pancreatitis risk lacked significant association with sample size, age, sex, cyst size, needle caliber, or passes, although we noted trends toward higher risk in studies published after 2015, those using higher gauge needles (19 G vs 22 G/25 G), and those performing EUS-guided through-the-needle biopsy.

DISCUSSION

We note with high certainty that pancreatitis after EUS-FNA of PCLs is infrequent and mild in severity with no mortality in the included cohort. EUS-guided through-the-needle biopsy may serve as a significant risk factor for EUS-FNA-related pancreatitis risk; however, further studies are needed to delineate other predisposing characteristics.

Development of an intraductal papillary mucinous neoplasm malignancy prediction scoring system

Despite the presence of various guidelines, diagnosing malignant intraductal papillary mucinous neoplasm (IPMN) continues to pose challenges. Furthermore, although endoscopic ultrasonography (EUS) offers high-resolution images, it has not yet recognized as the primary tool for malignancy diagnosis. The study objective was to develop a simplified and user-friendly scoring system to improve the diagnostic accuracy of malignant IPMNs. Additionally, the utility of EUS and its effect on diagnostic accuracy were assessed. We retrospectively collected the clinical data on 160 cases of resected IPMN at Tokyo Medical and Dental University Hospital from January 2008 to December 2022. We examined clinical features, computed tomography (CT) and magnetic resonance imaging (MRI) findings, and EUS results if available. We then calculated the odds ratio of malignancy for these factors and developed an IPMN malignancy prediction (IMAP) scoring system. There were 89 (55.6%) cases of benign IPMNs and 71 (44.4%) of malignant IPMNs. Eight clinical and imaging findings, including age, diabetes mellitus status, jaundice, CA19-9 level, enhancing mural nodules ≥5mm, thickened wall, and main duct dilatation, were significantly associated with malignancy. The IMAP score was calculated by assigning 0 to 2 points to these factors based on the odds ratio. The area under the receiver operating characteristic curve for the IMAP score was 0.78 [95% confidence interval (CI): 0.71-0.85] based on CT/MRI alone and improved to 0.81 (95% CI: 0.74-0.87) when EUS was added. When the total exceeds 5 points, the positive predictive value becomes 100% (95% CI: 95.9-100). In conclusion, the IMAP scoring system has demonstrated promise as a clinically useful tool, offering both simplicity and sufficient accuracy. It holds potential as an important decision criterion for determining the treatment approach for IPMN. Additionally, EUS contributes to enhancing the diagnostic accuracy of the IMAP scoring system, thereby enabling more precise decision-making.

Antibiotic prophylaxis in digestive endoscopy: Guidelines from the French Society of Digestive Endoscopy

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

Utility of Endoscopic Ultrasound-Guided Fine-Needle Aspiration in a Paediatric Population: A Single-Centre Experience

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a modern and minimally invasive technique to acquire diagnostic material from within the gastrointestinal tract, as well as from adjacent organs and structures, which can help in the diagnosis and staging of a variety of gastrointestinal malignancies, as well as for non-malignant conditions. Though well described in adults, there is limited literature on the diagnostic utility of EUS-FNA in paediatric patients. The objective of this study was to evaluate the diagnostic accuracy and clinical utility of EUS-FNA in paediatric patients performed at our centre over the last 17 years.

MATERIALS AND METHODS

After obtaining Institutional Review Board approval, 63 cases of paediatric EUS-FNA performed at SKMCH&RC from 2005 to 2022 were retrieved. A 22-gauge EUS-FNA needle was used for obtaining samples with the use of suction (when required). The sample was then smeared onto glass slides, with half being stained with RAPI stain while the rest with the Papanicolaou stain. Demographic details, indication for the procedure, results of rapid on-site adequacy status (ROSE), site of lesion, and cytological diagnosis were reviewed and analysed.

RESULTS

Of the 63 patients, 55 (87.3%) had an adequate sample (confirmed on ROSE). Forty-two (66.7%) were male and the mean age was 12.4 years. The most frequent indication of EUS-FNA was a sampling of enlarged lymph nodes (74.6%). The most common sites of nodal aspiration were sub-carinal (33.3%) and celiac lymph nodes (14.3%). EUS-FNA of a pancreatic lesion accounted for an additional 17.5% of cases. Involvement by Hodgkin's lymphoma was the most common diagnosis (25.4%) followed by granulomatous inflammation (19.1%). Cases of solid pseudo-papillary tumour (4.8%) and recurrent Wilm's tumour (3.2%) were also diagnosed. No patient suffered complications, and none required hospital admission, post-procedure. The sensitivity, specificity, PPV, and NPV of EUS-FNA were 98.1, 83.3, 96.4, and 90.9%, respectively.

CONCLUSION

EUS-FNA is a safe, well-tolerated, minimally invasive outpatient setting procedure with high sensitivity and significant utility in the diagnosis and staging of disease.

The role of endoscopic ultrasound in the detection of pancreatic lesions in high-risk individuals

Individuals at high risk of developing pancreatic ductal adenocarcinoma are eligible for surveillance within research programs. These programs employ periodic imaging in the form of magnetic resonance imaging/magnetic resonance cholangiopancreatography or endoscopic ultrasound for the detection of early cancer or high-grade precursor lesions. This narrative review discusses the role of endoscopic ultrasound within these surveillance programs. It details its overall strengths and limitations, yield, burden on patients, and how it compares to magnetic resonance imaging. Finally, recommendations are given when and how to incorporate endoscopic ultrasound in the surveillance of high-risk individuals.

Optimization of Endoscopic Ultrasound Characteristics in the Diagnosis of Malignant Intraductal Papillary Mucinous Neoplasm

OBJECTIVES

Endoscopic ultrasound (EUS) is an excellent diagnostic tool that provides high-resolution images of pancreatic cystic lesions. However, its role in the diagnosis of malignant intraductal papillary mucinous neoplasm (IPMN) remains limited and unclear. We aimed to determine the usefulness of this modality for such diagnosis.

METHODS

Overall, 246 patients who underwent EUS for IPMN after computed tomography (CT)/magnetic resonance imaging (MRI) from April 2018 to June 2021 were followed up until March 2022. We assessed the added value of performing EUS after CT or MRI for diagnosing malignant IPMN, using receiver operating characteristic curve analysis. Walls as thick as 2 mm were considered thickened in this study if they were highly uneven.

RESULTS

EUS clearly enhanced accuracy in identifying enhancing nodules and thickened walls. The areas under the receiver operating characteristic curve and corresponding 95% confidence intervals were 0.655 (0.549-0.760) and 0.566 (0.478-0.654) upon CT/MRI but 0.853 (0.763-0.942) and 0.725 (0.634-0.817) when observed using EUS. The combination of nodule size, thickened wall, and main duct size yielded the highest area under the receiver operating characteristic curve (0.944 [0.915-0.973]).

CONCLUSIONS

EUS more accurately detects malignant IPMN, as uneven wall thickening and certain nodules cannot be identified with CT/MRI.

Value of Endoscopic Ultrasound-Guided Through-the-Needle Biopsy in Pancreatic Cystic Lesions. A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs.

METHODS

Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models.

RESULTS

The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events.

CONCLUSIONS

EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis.

Absorbable cyst brushes

Cytobrushes are used for low-invasive sample collection and screening in multiple diseases, with a significant impact on early detection, prevention, and diagnosis. This study focuses on improving the safety of cell brushing in hard-to-reach locations by exploring brush construction from absorbable materials. We investigated the efficacy of loop brushes made of absorbable suture wires of Chirlac, Chirasorb, Monocryl, PDS II, Vicryl Rapid, Glycolon, and Catgut during their operation in conjunction with fine-needle aspiration in an artificial cyst model. PDS II brushes demonstrated the highest efficiency, while Monocryl and Catgut also provided a significant brushing effect. Efficient brushes portrayed higher flexural rigidity than their counterparts, and their efficiency was inversely proportional to their plastic deformation by the needle. Our results open avenues for safer cell biopsies in hard-to-reach locations by utilizing brushes composed of absorbable materials.

Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review

Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. Endoscopic ultrasound has a multifactorial role in delineating the morphology of pancreatic cystic lesions, ranging from fluid and tissue acquisition for analysis-fine needle aspiration and through-the-needle biopsy, respectively-to advanced imaging techniques, such as contrast-harmonic mode endoscopic ultrasound and EUS-guided needle-based confocal laser endomicroscopy. In this review, we will summarize and provide an update on the specific role of EUS in the management of pancreatic cystic lesions.

The clinical impact of endoscopic ultrasound-guided fine-needle aspiration on the patients with low-risk pancreatic cystic lesions

Background and aims

Endoscopic ultrasound (EUS) is playing a more and more important role in the management of pancreatic cystic lesion (PCLs). The aim of our study was to evaluate the clinical impact of EUS and EUS guided fine needle aspiration (FNA) on patients with low-risk PCLs.

Materials and methods

Low-risk PCL patients who underwent EUS-FNA in 2 edoscopic centers were retrospectively collected and analyzed. The clinical impact of EUS-FNA on these patients was analyzed and the predictors for significance EUS-FNA (defined by diagnosis and treatment method change, new high-risk feature identified after imaging scans) were analyzed by logistic regression analyses.

Results

From July 2004 to February 2017, 186 patients with low-risk PCLs were included. The study cohort had a mean age of 52.4 ± 15.9 years (range: 19-86 years) with 89 (47.8%) male patients included. The clinical significance of EUS-FNAs was observed in 74 patients (39.8%). The presumed diagnoses of PCLs by imaging were changed in 51 (51/74, 68.9%) patients. Nineteen (19/74, 25.7%) new high-risk features were identified by EUS-FNA, and four patients (4/74, 5.4%) underwent surgery due to suspicious or malignant cytology. Based on multivariate analysis, large cyst size [odds ratio (OR): 1.12, 95% confidence interval (CI): 1.02–1.19, P = 0.033], young age (OR: 0.94, 95% CI: 0.91–0.99, P = 0.041) and BMI over 25 (OR: 3.15, 95% CI: 1.29–7.86, P = 0.013) were independent predictors of clinical significance for EUS-FNA. The optimal age and cyst size to predict significance EUS-FNA was 46.0 years and 2.3cm.

Conclusions

On the basis of a 2-center retrospective study, EUS-FNA was clinically significant in about 40% of low-risk PCLs, especially in young, large cyst size, and overweight patients.

Advances in the Diagnosis of Pancreatic Cystic Lesions

Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant. There has been an increase in PCLs prevalence in recent years, mostly due to advances in imaging techniques, increased awareness of their existence and population aging. Reliable discrimination between neoplastic and non-neoplastic cystic lesions is paramount to ensuring adequate treatment and follow-up. Although conventional diagnostic techniques such as ultrasound (US), magnetic resonance imaging (MRI) and computer tomography (CT) can easily identify these lesions, assessing the risk of malignancy is limited. Endoscopic ultrasound (EUS) is superior to cross-sectional imaging in identifying potentially malignant lesions due to its high resolution and better imaging characteristics, and the advantage of allowing for cyst fluid sampling via fine-needle aspiration (FNA). More complex testing, such as cytological and histopathological analysis and biochemical and molecular testing of the aspirated fluid, can ensure an accurate diagnosis.

Application of Artificial Intelligence in the Management of Pancreatic Cystic Lesions

The rate of incidentally detected pancreatic cystic lesions (PCLs) has increased over the past decade and was recently reported at 8%. These lesions pose a unique challenge, as each subtype of PCL carries a different risk of malignant transformation, ranging from 0% (pancreatic pseudocyst) to 34–68% (main duct intraductal papillary mucinous neoplasm). It is imperative to correctly risk-stratify the malignant potential of these lesions in order to provide the correct care course for the patient, ranging from monitoring to surgical intervention. Even with the multiplicity of guidelines (i.e., the American Gastroenterology Association guidelines and Fukuoka/International Consensus guidelines) and multitude of diagnostic information, risk stratification of PCLs falls short. Studies have reported that 25–64% of patients undergoing PCL resection have pancreatic cysts with no malignant potential, and up to 78% of mucin-producing cysts resected harbor no malignant potential on pathological evaluation. Clinicians are now incorporating artificial intelligence technology to aid in the management of these difficult lesions. This review article focuses on advancements in artificial intelligence within digital pathomics, radiomics, and genomics as they apply to the diagnosis and risk stratification of PCLs.

Adverse Event Fatalities Related to GI Endoscopy

BACKGROUND

Death after endoscopy is rare, under-reported, and has variable causes. This study aimed to evaluate the incidence and causes of fatal endoscopic adverse events (AEs) across two academic medical centers and to identify patient-, procedure-, and sedation-related risk factors.

METHODS

This is a retrospective cohort study of fatal adverse events causally related to endoscopy at Denver Health Medical Center and the University of Colorado Hospital from 2011 to 2020. Fatal AEs were retrieved from the physician-reported database. Electronic medical records were then reviewed to determine medical history, procedure details, subsequent treatments, and time and cause of death.

RESULTS

From January 2011 to January 2020, 146,010 GI endoscopy procedures were performed. Median patient age was 70 [51-78] and 57% were male. Thirty-one deaths were identified, 28 of which were attributed to endoscopy, yielding a procedure-related fatality rate of 0.018%. Procedures included 11 EGDs, one colonoscopy, two flexible sigmoidoscopies, six ERCPs, seven upper EUS, and one PEG-J tube placement. Specific causes of death included aspiration in four patients (14%); cardiac arrest or myocardial infarction in seven patients (25%); perforation in nine patients (32%); bleeding in four patients (14%); cholangitis or sepsis without perforation in three patients (11%); and acute pancreatitis in one patient (3.6%).

CONCLUSIONS

Fatal endoscopic AEs were rare but tended to occur in older patients with major comorbidities. Most deaths occurred from aspiration pneumonia, cardiac arrest, or perforation-related sepsis within 1 week of the procedure.

Exploring the Clinical Utility of Pancreatic Cancer Circulating Tumor Cells

Pancreatic ductal adenocarcinoma (PDAC) is the most frequent pancreatic cancer type, characterized by a dismal prognosis due to late diagnosis, frequent metastases, and limited therapeutic response to standard chemotherapy. Circulating tumor cells (CTCs) are a rare subset of tumor cells found in the blood of cancer patients. CTCs has the potential utility for screening, early and definitive diagnosis, prognostic and predictive assessment, and offers the potential for personalized management. However, a gold-standard CTC detection and enrichment method remains elusive, hindering comprehensive comparisons between studies. In this review, we summarize data regarding the utility of CTCs at different stages of PDAC from early to metastatic disease and discuss the molecular profiling and culture of CTCs. The characterization of CTCs brings us closer to defining the specific CTC subpopulation responsible for metastasis with the potential to uncover new therapies and more effective management options for PDAC.

Machine learning principles applied to CT radiomics to predict mucinous pancreatic cysts

PURPOSE

Current diagnostic and treatment modalities for pancreatic cysts (PCs) are invasive and are associated with patient morbidity. The purpose of this study is to develop and evaluate machine learning algorithms to delineate mucinous from non-mucinous PCs using non-invasive CT-based radiomics.

METHODS

A retrospective, single-institution analysis of patients with non-pseudocystic PCs, contrast-enhanced computed tomography scans within 1 year of resection, and available surgical pathology were included. A quantitative imaging software platform was used to extract radiomics. An extreme gradient boosting (XGBoost) machine learning algorithm was used to create mucinous classifiers using texture features only, or radiomic/radiologic and clinical combined models. Classifiers were compared using performance scoring metrics. Shapely additive explanation (SHAP) analyses were conducted to identify variables most important in model construction.

RESULTS

Overall, 99 patients and 103 PCs were included in the analyses. Eighty (78%) patients had mucinous PCs on surgical pathology. Using multiple fivefold cross validations, the texture features only and combined XGBoost mucinous classifiers demonstrated an area under the curve of 0.72 ± 0.14 and 0.73 ± 0.14, respectively. By SHAP analysis, root mean square, mean attenuation, and kurtosis were the most predictive features in the texture features only model. Root mean square, cyst location, and mean attenuation were the most predictive features in the combined model.

CONCLUSION

Machine learning principles can be applied to PC texture features to create a mucinous phenotype classifier. Model performance did not improve with the combined model. However, specific radiomic, radiologic, and clinical features most predictive in our models can be identified using SHAP analysis.

Pancreaticobiliary endoscopic ultrasound in England 2007 to 2016: Changing practice and outcomes

Background and study aims  Population-level data on the outcomes of pancreaticobiliary endoscopic ultrasound (PB-EUS) are limited. We examined national PB-EUS and fine-needle aspiration (FNA) activity, its relation to pancreatic cancer therapy, associated mortality and adverse events. Patients and methods  Adults undergoing PB-EUS in England from 2007-2016 were identified in Hospital Episode Statistics. A pancreatic cancer cohort diagnosed within 6 months of PB-EUS were studied separately. Multivariable logistic regression models examined associations with 30-day mortality and therapies for pancreatic cancer. Results  79,269 PB-EUS in 68,908 subjects were identified. Annual numbers increased from 2,874 (28 % FNA) to 12,752 (35 % FNA) from 2007 to 2016. 8,840 subjects (13 %) were diagnosed with pancreatic cancer. Sedation related adverse events were coded in 0.5 % and emergency admission with acute pancreatitis in 0.2 % within 48 hours of PB-EUS. 1.5 % of subjects died within 30 days of PB-EUS. Factors associated with 30-day mortality included increasing age (odds ratio 1.03 [95 % CI 1.03-1.04]); male sex (1.38 [1.24-1.56]); increasing comorbidity (1.49 [1.27-1.74]); EUS-FNA (2.26 [1.98-2.57]); pancreatic cancer (1.39 [1.19-1.62]); increasing deprivation (least deprived quintile 0.76 [0.62-0.93]) and lower provider PB-EUS volume (2.83 [2.15-3.73]). Factors associated with surgical resection in the pancreatic cancer cohort included lower provider PB-EUS volume (0.44 [0.26-0.74]) and the least deprived subjects (1.33 [1.12-1.57]). 33 % of pancreatic cancer subjects who underwent EUS, did not subsequently receive active cancer treatment. Conclusions  Lower provider PB-EUS volume was associated with higher 30-day mortality and reduced rates of both pancreatic cancer surgery and chemotherapy. These results suggest potential issues with case selection in lower-volume EUS providers.

Fine-needle aspiration of pancreatic cystic lesions: a randomized study with long-term follow-up comparing standard and flexible needles

BACKGROUND

Pancreatic cystic lesions (PCLs) are increasingly found on cross-sectional imaging, with the majority having a low risk for malignancy. The added value of fine-needle aspiration (FNA) in risk stratification remains unclear. We evaluated the impact of three FNA needles on diagnostic accuracy, clinical management, and the ability to accrue fluid for tumor markers.

METHODS

A multicenter prospective trial randomized 250 patients with PCLs ≥ 13 mm 2:1:1 to 19G Flex, 19G, and 22G needles with crossover for repeated FNA procedures. Diagnostic accuracy was established at 2-year follow-up, with the final diagnosis from surgical histopathology or consensus diagnosis by experts based sequentially on clinical presentation, imaging, and aspirate analysis in blinded review.

RESULTS

Enrolled patients (36 % symptomatic) had PCLs in the head (44 %), body (28 %), and tail (26 %). Percentage of cyst volume aspirated was 78 % (72 % - 84 %) for 19G Flex, 74 % (64 % - 84 %) for 22G, and 73 % (63 % - 83 %) for 19G (P = 0.84). Successful FNA was significantly higher for 19G Flex (89 % [82 % - 94 %]) and 22G (82 % [70 % - 90 %]) compared with 19G (75 % [63 % - 85 %]) (P = 0.02). Repeated FNA was required more frequently in head/uncinate lesions than in body and tail (P < 0.01). Diagnostic accuracy of the cyst aspirate was 84 % (73 % - 91 %) against histopathology at 2-year follow-up (n = 79), and 77 % (70 % - 83 %) against consensus diagnosis among nonsurgical cases (n = 171). Related serious adverse events occurred in 1.2 % (0.2 % - 3.5 %) of patients.

CONCLUSIONS

Our study results demonstrate a statistically significant difference among the three needles in the overall success rate for aspiration, but not in the percentage of cyst volume aspirated. Flexible needles may be particularly valuable in sampling cystic PCLs in the pancreatic head/uncinate process.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Risk of adverse events associated with upper and lower endoscopic ultrasound: a population-based cohort study

Background and study aim  Endoscopic ultrasound (EUS) enables diagnostic evaluation and therapeutic interventions but is associated with adverse events. We conducted a population-based cohort study to determine the risk of adverse events for upper and lower EUS with and without fine-needle aspiration (FNA). Patients and methods  All adults who underwent EUS and resided in Calgary in 2007-2013 were included. Endoscopy and provincial databases were used to identify EUS procedures, unplanned emergency department visits, and hospital admissions within 30 days of the procedures, which were then characterized through formal chart review. Adverse events were defined a priori and classified as definitely, possibly, or not related to EUS. The primary outcome was 30-day risk of adverse events classified as definitely or possibly related to EUS. Univariable and multivariable analyses were conducted with risk factors known to be associated with EUS adverse events. Results  2895 patients underwent 3552 EUS procedures: 3034 (85 %) upper EUS, of which 710 (23 %) included FNA, and 518 (15 %) lower EUS, of which 23 (4 %) involved FNA. Overall, 69 procedures (2 %) involved an adverse event that was either definitely or possibly related to EUS, with 33 (1 %) requiring hospitalization. None of the adverse events required intensive care or resulted in death. On multivariable analysis, only FNA was associated with increased risk of adverse events (odds ratio 6.43, 95 % confidence interval 3.92-10.55; P  < 0.001). Conclusion  Upper and lower EUS were generally safe but FNA substantially increased the risk of adverse events. EUS-related complications requiring hospitalization were rare.

Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis

Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.

Endoscopic drainage for management of infected necrosis following EUS-TA in a patient with pancreatic cancer: A case report

RATIONALE

Endoscopic ultrasonography-guided tissue acquisition (EUS-TA) has become the norm for the diagnosis of pancreatic solid lesions. EUS-TA is relatively safe, but various complications can occur. Infected pancreatic necrosis (IPN) is a rare but serious complication. The latest guidelines suggest that all invasive interventions in patients with IPN should be delayed until walled-off necrosis appears.

PATIENT CONCERNS

A 73-year-old man was referred to our hospital with double primary cancers including gallbladder and pancreas. We performed EUS-TA on metastatic pancreatic tail cancer to confirm histologic diagnosis. Six days after the procedure, he developed abdominal pain and fever.

DIAGNOSES

The patient's laboratory findings showed leukocytosis and C-reactive protein elevation. Fluid collection around pancreas tail and stomach was detected in computed tomography (CT) scan, and the patient was diagnosed with IPN.

INTERVENTIONS AND OUTCOMES

EUS-guided endoscopic transmural drainage (EUS-TD) was performed for the treatment of IPN. Two days after the procedure with antibiotics, his CRP level decreased abruptly, and he received chemotherapy for the treatment of pancreatic ductal adenocarcinoma (PDAC) 5 days after the procedure. He was discharged from our hospital without complications 15 days after chemotherapy.

LESSONS

In selected patients with PDAC, early endoscopic drainage may be recommended as treatment for IPN resulting from complications of EUS-TA.

Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass: A case report

BACKGROUND

Endoscopic ultrasound-guided fine needle aspiration or biopsy (EUS-FNA or FNB) has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety. To the best of our knowledge, no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described. Herein, we report a rare case of septic shock after EUS-FNB of a splenic mass.

CASE SUMMARY

A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass. A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging. EUS of the spleen showed a 6 cm-sized, relatively well-demarcated, heterogeneous mass, and EUS-FNB with a 22G needle was performed. Ten days after the procedure patient developed septic shock and a splenic abscess was identified. Blood culture revealed growth of Granulicatella adiacens. After the treatment with antibiotics the patient underwent surgical resection, and the pathological examination showed diffuse large B-cell lymphoma. The patient received chemotherapy and he is in complete remission.

CONCLUSION

Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.

Histopathological evaluation of needle tract seeding caused by EUS-fine-needle biopsy based on resected specimens from patients with solid pancreatic masses: An analysis of 73 consecutive cases

Background and Objectives:

EUS-guided fine-needle biopsy (EUS-FNB) is considered a safe and useful method for preoperative diagnosis of resectable solid pancreatic masses. However, needle tract seeding (NTS) after EUS-FNB has recently been reported, which may affect long-term outcome. The aim of this study was to evaluate NTS after EUS-FNB.

Materials and Methods:

We reviewed 73 resected cases that underwent preoperative EUS-FNB for a pancreatic tumor from April 2014 to March 2016 and evaluated the utility and adverse events of EUS-FNB based on consecutively resected pathological specimens.

Results:

The final diagnoses were pancreatic ductal adenocarcinoma (n = 67), neuroendocrine neoplasm (n = 5), and acinar cell carcinoma (n = 1). The diagnostic accuracy of preoperative EUS-FNB was 98.6%. Clinical adverse events were observed in 4.1% of cases (bleeding, n = 2; acute pancreatitis, n = 1) and abnormal pathological findings in 4.1% (NTS, n = 2; acute focal pancreatitis, n = 1).

Conclusions:

Although EUS-FNB is useful for preoperative diagnosis of pancreatic tumors, we may need to reconsider the risk of NTS and use of EUS-FNB in patients with a resectable solid pancreatic mass unless the tract itself is planned to be resected.

EUS-guided biopsy versus confocal laser endomicroscopy in patients with pancreatic cystic lesions: A systematic review and meta-analysis

Background and Objectives:

Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods.

Methods:

This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success.

Results:

Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07).

Conclusion:

EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.

The role of solid debris in endoscopic ultrasound-guided drainage of walled-off necrosis: A large cohort study

BACKGROUND AND AIM

The effect of solid debris on walled-off necrosis (WON) drainage remains unknown. Our study evaluated the role of solid debris in endoscopic ultrasound (EUS)-guided drainage of WON compared lumen-apposing metal stent (LAMS) with double-pigtail plastic stent (DPPS).

METHODS

We retrospectively evaluated consecutive patients with WON who underwent EUS-guided drainage in our endoscopic center over a 9-year period. The amount of solid debris in WON was assessed with computed tomography or magnetic resonance imaging and EUS images.

RESULTS

From 2011 to 2019, 84 WON patients were included. In WON with < 20% solid debris, the short-term clinical success of LAMSs (96.8%) was significantly higher than DPPSs (66.7%) (P = 0.03), and LAMSs were safer than DPPSs with less early adverse events (P = 0.02) and late adverse events (P = 0.03). On multivariable analysis, DPPS (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.04-0.65; P = 0.01) and solid debris > 40% (OR, 0.11; 95% CI, 0.02-0.62; P = 0.01) were the predictors for failure of resolution of WON after adjusting for age and cyst size. The number of DPPSs used was significantly higher than LAMSs in managing WONs (P < 0.001).

CONCLUSION

For WON with < 20% solid debris, LAMSs might superior to DPPSs in terms of efficacy and safety.

The usefulness of EUS-FNA with contrast-enhanced harmonic imaging of solid pancreatic lesions: A prospective study

BACKGROUND AND AIM

Few studies have investigated endoscopic ultrasound-guided fine-needle aspiration with contrast-enhanced harmonic imaging (EUS-FNA-CHI) for diagnosing and adequately sampling pancreatic lesions. This study aimed to investigate the efficacy of EUS-FNA-CHI compared with that of endoscopic ultrasound-guided fine-needle aspiration with fundamental B mode imaging (EUS-FNA-FBI) for diagnosing solid pancreatic lesions.

METHODS

Consecutive patients with solid pancreatic lesions were enrolled prospectively (UMIN 000024467). Only samples obtained during the first needle pass (EUS-FNA-FBI) and second needle pass (EUS-FNA-CHI) were used to compare the accuracy rate for diagnosing pancreatic lesions and rate of adequate sampling for histological evaluation. In patients with hypo-enhancing lesions on contrast-enhanced harmonic EUS (CH-EUS), subgroup analyses were performed. Patients were classified into those with a heterogeneous area in the whole lesion (whole group), those with a heterogeneous area with a non-enhancing area (non-enhancing group), and those with a heterogeneous area with a homogeneous area (homogeneous group).

RESULTS

Ninety-three patients were enrolled. Overall, the rates of adequate sampling and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI (84.9% vs 68.8%, P = 0.003 and 76.5% vs 58.8%, P = 0.011, respectively). The adequate sampling rate and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI when the mass was > 15 mm. In the non-enhancing and homogeneous groups, the adequate sampling rate and sensitivity were significantly higher with EUS-FNA-CHI than with EUS-FNA-FBI.

CONCLUSIONS

CH-EUS enables improved observation of pancreatic lesions and helps identify the target of EUS-FNA among different pathological areas of the lesions particularly of > 15 mm.

Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Narrative Review

Considerable progress has been made recently in the use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to diagnose intra-luminal gastrointestinal lesions and extra-luminal lesions near the gastrointestinal tract. Numerous reports have indicated that EUS-FNA has high diagnostic performance and safety, which has led to the routine use of EUS-FNA and an increasing number of cases. Thus, while EUS-FNA has a low rate of complications, endoscopists may encounter these complications as the number of cases increases. Infrequent reports have also described life-threatening complications. Therefore, endoscopists should possess a comprehensive understanding of the complications of EUS-FNA, which include hemorrhage, perforation, infection, and acute pancreatitis, as well as their management. This review examines the available evidence regarding the complications associated with EUS-FNA, and the findings will be useful for ensuring that endoscopists perform EUS-FNA safely and appropriately.

Confocal endomicroscopy for evaluation of pancreatic cystic lesions: a systematic review and international Delphi consensus report

Background and study aims  The aim of thi systematic review and consensus report is to standardize the practice of endoscopic ultrasound (EUS-guided needle-based confocal laser endomicroscopy (nCLE) for pancreatic cystic lesion (PCL) evaluation. Methods  We performed an international, systematic, evidence-based review of the applications, outcomes, procedural processes, indications, training, and credentialing of EUS-nCLE in management of PCLs. Based on available clinical evidence, preliminary nCLE consensus statements (nCLE-CS) were developed by an international panel of 15 experts in pancreatic diseases. These statements were then voted and edited by using a modified Delphi approach. An a priori threshold of 80 % agreement was used to establish consensus for each statement. Results  Sixteen nCLE-CS were discussed. Thirteen (81 %) nCLE-CS reached consensus addressing indications (non-communication PCL meeting criteria for EUS-FNA or with prior non-diagnostic EUS-FNA), diagnostic outcomes (improved accuracy for mucinous PCLs and serous cystadenomas with substantial interobserver agreement of image patterns), low incidence of adverse events (fluorescein-associated and pancreatitis), procedural processes (nCLE duration, manipulation of needle with probe), and training (physician knowledge and competence). Conclusion  Based on a high level of agreement pertaining to expert consensus statements, this report standardizes the practice of EUS-nCLE. EUS-nCLE should be systematically considered when EUS-FNA is indicated for PCL evaluation.

Overlooked risk for needle tract seeding following endoscopic ultrasound-guided minimally invasive tissue acquisition

Endoscopic ultrasound-guided minimally invasive tissue acquisition can be performed by two approaches as follows: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). These have been evolved into leading approaches and widely used for the histological diagnosis of tumors in the gastrointestinal tract and adjacent organs. However, the role of EUS-FNA and EUS-FNB in disease diagnosis and evaluation remains controversial. Although the incidence of surgery-associated complications remains low, the consequences of needle tract seeding can be serious or even life-threatening. Recently, increasing case reports of needle tract seeding are emerging, especially caused by EUS-FNA. This complication needs serious consideration. In the present work, we integrated these case reports and the related literature, and summarized the relevant cases and technical characteristics of needle tract seeding caused by EUS-FNA and EUS-FNB. Collectively, our findings provided valuable insights into the prevention and reduction of such serious complication.

Imaging features and pathological evaluation by EUS-FNA enable conservative management in patient of lymphoepithelial cyst of the pancreas: a case report

Pancreatic lymphoepithelial cysts (LECs) are rare cystic lesions filled with a keratinous substance and lined by squamous epithelium with underlying lymphoid tissue. Because pancreatic LECs are entirely benign, correct preoperative diagnosis is important to avoid unnecessary surgery. However, the imaging features of pancreatic LECs are not specific and preoperative diagnosis has proven difficult. A pancreatic mass was incidentally detected through abdominal ultrasonography in a 63-year-old male presenting without any symptoms. Computed tomography showed an exophytic cystic lesion in the pancreatic head. The lesion had heterogeneous high signal intensity with partial low intensity on T2-weighted magnetic resonance imaging (MRI) and high signal intensity on diffusion MRI. Endoscopic ultrasound (EUS) examination showed an encapsulated cystic lesion with relatively homogenous and highly echoic contents. EUS-guided fine-needle aspiration (EUS-FNA) revealed caseous appearance and rare fragments of apparently benign squamous epithelium on a background of keratinous debris, cyst contents, and scattered lymphocytes. We diagnosed a pancreatic LEC and opted for conservative management without surgery. Pathological evaluation based on images obtained through EUS-FNA showed macro- and microscopic features that were critical to determining the management strategy. In conclusion, the imaging and pathological features of pancreatic LECs can inform preoperative diagnosis, which may enable conservative management.

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND/OBJECTIVES

This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy.

METHODS

An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements.

RESULTS

Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

EUS-FNA, ancillary studies and their clinical utility in patients with mediastinal, pancreatic, and other abdominal lesions

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important modality to obtain tissue diagnosis from mediastinal, pancreatic, and intra-abdominal lesions in close proximity to the pulmonary and gastrointestinal tract. It is considered to be a relatively safe, rapid, and minimally invasive technique with low complication rates.

AIMS

To determine the diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and outcome of EUS-FNA, with histological correlation where applicable.

METHODS

Data of all 1059 consecutive patients who underwent EUS-FNA from 1 January 2005 to 31 December 2017 at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore was reviewed in this retrospective study. The major sites that were targeted for EUS-FNA were pancreatic (423), mediastinal (376), and other abdominal lesions (260).

RESULTS

The average number of passes per patient was 2.22. Rapid on-site evaluation (ROSE) was adequate in 969 patients (91.4%). Concordance between ROSE and final cytology was 99.5%. Follow-up was available in 810 patients (76.4%). The overall diagnostic yield was 94.3%. Ancillary studies, including immunohistochemical stains and flow cytometry, helped to increase the diagnostic yield from 78.1% to 94.3%. The overall sensitivity, specificity, PPV, NPV, and diagnostic accuracy for EUS-FNA were 94.8%, 98.6%, 99.9%, 65.5%, and 95.1%, respectively. Seven of 1059 patients (0.6%) developed complications.

CONCLUSION

EUS-FNA is a very sensitive and specific diagnostic tool with a minimal complication rate. Ancillary studies helped to increase the sensitivity, as well as the diagnostic yield.

Management of Incidental Pancreatic Cystic Lesions: Integrating Novel Diagnostic and Prognostic Factors With Current Clinical Guidelines

Owing to increased detection rates, the diagnosis and management of incidental pancreatic cysts has become a common predicament. Up to 13% of patients undergoing cross-sectional imaging studies for other indications are found to have pancreatic cystic lesions. Although most cystic lesions are benign, the malignant potential of several types of pancreatic cysts makes accurate classification vital to directing therapy. To this end, advances in the last decade led to better characterization of pancreatic cyst morphology and hence enhanced the ability to predict underlying histopathology, and biological behavior. Although accurate classification remains a challenge, the utilization of complementary diagnostic tools is the optimal approach to dictate management. The following review includes a description of pancreatic cysts, a critical review of current and emerging diagnostic techniques and a review of recent guidelines in the management of incidental pancreatic cysts.

Antibiotic Prophylaxis Is Not Required for Endoscopic Ultrasonography-Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions, Based on a Randomized Trial

BACKGROUND & AIMS

Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection.

METHODS

We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events.

RESULTS

The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, -0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events.

CONCLUSIONS

In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

Endoscopic Ultrasound-Guided Fine-Needle Aspiration Microhistology in Asymptomatic and Symptomatic Pancreatic Cystic Lesions

OBJECTIVE

This study aimed to analyze the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) microhistology to detect malignancy in pancreatic cystic lesions (PCLs).

METHODS

Patients with PCLs were identified and submitted to EUS-FNA from January 2010 to January 2017. The percentage of samples suitable for diagnostic classification by microhistology and the positive and negative likelihood ratios to detect malignancy in asymptomatic (APC) and symptomatic (SPC) PCLs were determined.

RESULTS

Endoscopic ultrasound-guided fine-needle aspiration was performed in 510 patients. The resulting material was processed by microhistology and useful for diagnosis in 432 (84.2%). Clinical characteristics of APC (341) and SPC (169) revealed that APC patients were younger (P = 0.004) and had smaller PCLs (23 vs 35 mm; P < 0.001). In APC, we found more preneoplastic (38.7% vs 30.2%; P = 0.0016) and a lower number of malignant PCLs (8.2% vs 24.3%; P < 0.001). In APC and SPC, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of microhistology to detect malignancy were 71.4%, 99.7%, 95.2%, 97.5%, and 97.4% (k = 0.80) and 58.5%, 96.9%, 85.7%, 87.9%, and 87.6%, respectively.

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle aspiration was technically feasible. Microhistology was especially useful to detect neoplastic or malignant PCLs in APC patients.

Seeding of a Tumor in the Gastric Wall after Endoscopic Ultrasound-guided Fine-needle Aspiration of Solid Pseudopapillary Neoplasm of the Pancreas

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is widely used as a first-line procedure for the definitive diagnosis of pancreatic solid tumor. Adverse events associated with the EUS-FNA procedure include acute pancreatitis, bleeding, infection, and duodenal perforation. Rarely, pancreatic tumors disseminate in the peritoneal cavity or seed in the gastric wall via the biopsy needle tract after EUS-FNA. Such seeding has been noted primarily in cases of adenocarcinomas and has not been associated with solid pseudopapillary neoplasm (SPN), a rare and potentially malignant tumor of the pancreas. This is the first report of a case of tumor seeding in the gastric wall after EUS-FNA of pancreatic SPN.