Background: Recent advances in EUS techniques (real-time EUS elastography and contrast-enhanced EUS) have allowed a better characterization of focal pancreatic masses. Mean strain histograms (SHs) are considered a good parameter for the semi-quantitative evaluation of focal pancreatic masses, alongside complementary contrast-enhanced EUS parameters which can be quantified during both the early arterial and late venous phase. Materials and Methods: The study design was prospective, blinded, and multicentric, assessing real-time EUS elastography and contrast-enhanced EUS results for the characterization of focal pancreatic masses using parametric measurements, in comparison with pathology which is the gold standard. SHs were performed based on the embedded software of the ultrasound system, with the values being reversed as opposed to our initially published data on hue histograms. Consequently, a cutoff of 80 was derived from previous multicentric trials. Contrast-enhanced EUS also allowed the focal masses to be classified as hyper-, iso-, or hypoenhanced in comparison with the normal pancreatic parenchyma. EUS-FNA was then performed for all patients, with a positive cytological diagnosis taken as a final proof of malignancy for the pancreatic masses. The diagnoses obtained by EUS-FNA were verified further either by surgery or during a clinical follow-up of at least 6 months. Results: A total number of 97 consecutive patients with focal pancreatic masses were included in the study. Based on previously defined cutoffs of 80, the values of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the mean SHs for the diagnosis of pancreatic cancer were 100%, 29.63%, 78.65%, 100%, and 80.41%, respectively. Corresponding values for contrast-enhanced EUS (taking into consideration hypoenhencement as a predictive factor of malignancy) were 98.57%, 77.78%, 92%, 95.45%, and 92.78%, respectively. Combining contrast enhancement-EUS (hypoenhencement) and semi-quantitative EUS elastography (SH cutoffs <80), the resulting values corresponding for sensitivity, specificity, and accuracy were 98.57%, 81.48%, and 93.81%, respectively. Conclusion: The current study using objective parametric tools for both EUS elastography and contrast-enhanced EUS confirmed the results of previous studies and meta-analyses that indicated a complementary role for the differential diagnosis of focal pancreatic masses. Moreover, the best values for the receiver operating curves were obtained using a sequential clinical algorithm based on the initial use of elastography, followed by contrast enhancement.

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ERCP is the current procedure of choice for patients with jaundice caused by biliary obstruction. EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP in patients requiring biliary drainage. The aim of the study was to conduct a systematic review and meta-analysis to report the overall efficacy and safety of EUS-BD. We conducted a comprehensive search of several databases including PubMed, EMBASE, Web of Science, Google Scholar, and LILACS databases (earliest inception to June 2018) to identify studies that reported EUS-BD in patients. The primary outcome was to look at the technical and clinical success of the procedure. The secondary analysis focused on calculating the pooled rate of re-interventions and all adverse-events, along with the commonly reported adverse-event subtypes. Twenty-three studies reporting on 1437 patients were identified undergoing 1444 procedures. Majority of the patient population were male (53.86%), with an average age of 67.22 years. The pooled technical success rates and clinical success rates were 91.5% (95% confidence interval [CI]: 87.7–94.2, I^[2] = 76.5) and 87% (95% CI: 82.3–90.6, I^[2] = 72.4), respectively. The total adverse event rates were 17.9% (95% CI: 14.3–22.2, I^[2] = 69.1). Subgroup analysis of three major individual adverse events was bile leak: 4.1% (2.7–6.2, I^[2] = 46.7), stent migration: 3.9% (2.5–6.2, I^[2] = 43.5), and infection: 3.8% (2.8–5.1, I^[2] = 0) Substantial heterogeneity was noted in the analysis. EUS-BD has high technical and clinical success rate and hence a very effective procedure. Concerns about publication bias exist. Careful consideration should be given to the adverse events and weighing the risks and benefits of the alternative nonsurgical/surgical approaches.

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The development of curvilinear-array EUS and EUS-guided fine-needle aspiration (EUS-FNA) has led these approaches to become interventional procedures rather than purely diagnostic, as a minimally invasive antitumor therapeutic alternative to radiological and surgical treatments. The possibility to accurately position needle devices and to reach a deep target like the pancreas gland under real-time imaging guidance has expanded the use of EUS to ablate tumors. Currently, a variety of probes specifically designed for EUS ablation are available, including radiofrequency, hybrid cryothermal ablation (combining radiofrequency with cryotechnology), photodynamic therapy, and laser ablation. To date, several studies have demonstrated the safety and feasibility of these ablation techniques in the pancreatic setting, but only a few small series on pancreatic thermal ablation under EUS guidance are available. EUS-guided thermal ablation is primarily used for pancreatic cancer. It is well suited to this disease because of its superior anatomical access compared with other imaging modalities and the dismal prognosis despite improvements in chemoradiotherapy and surgery in the management of pancreatic cancer. Other targets are pancreatic neuroendocrine tumors and pancreatic cystic neoplasms, which are curable by surgical resection, but some patients are poor surgical candidates or prefer conservative management. This is a literature review of previously published clinical studies on EUS-guided thermal ablative therapies. Data on the long-term efficacy of EUS-guided antitumor thermal ablation therapy and large prospective randomized studies are still needed to confirm the real clinical benefits of these techniques for the management of pancreatic neoplasms.

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Background and Objective: EUS-guided hepaticogastrostomy (HGS) is performed for patients with advanced cancer because of poor prognosis and compromised status, and bile peritonitis may prove critical for such patients. This adverse event has the possibility of decreasing quality of life by prolonging the time until the start of oral intake, hospital stay, or chemotherapy. Predictors of bile peritonitis in EUS-HGS thus have considerable clinical impact. The aim of this study was to retrospectively determine risk factors of bile peritonitis as adverse events of EUS-HGS. Patients and Methods: As risk factors of bile peritonitis, baseline characteristics of patients, characteristics of procedures such as number of punctures, types of fistula dilation, mean procedure time were analyzed. Furthermore, a receiver operating characteristic (ROC) curve was plotted to assess the influence of this distance and bile peritonitis and determine the optimum cutoff score for predicting the risk of bile peritonitis. Multivariate analysis using logistic regression was performed to examine factors of bile peritonitis. Results: A total of 68 patients were enrolled in this study. A distance of 2.50 cm offered 90.3% sensitivity and 87.5% specificity in predicting bile peritonitis according to the ROC curve. Number of punctures (>1), procedure time (>20 min), distance to the hepatic parenchyma (<2.50 cm), and presence of acute cholangitis were significantly associated with bile peritonitis in univariate analysis. However, according to this multivariate analysis, distance to the hepatic parenchyma (<2.50 cm, odds ratio 96.98, 95% confidence interval 10.12–929.12, P < 0.001) were only significantly associated with bile peritonitis. Conclusions: The short distance of hepatic parenchyma may be a risk factor of bile peritonitis.

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Background: Long-term indwelling transmural stents in patients with walled-off necrosis (WON) and disconnected pancreatic duct syndrome (DPDS) is an effective strategy to decrease risk of recurrence of pancreatic fluid collection (PFC). However, long-term studies on the safety and efficacy of this strategy are lacking. Methods: Retrospective analysis of database of patients with WON treated with endoscopic transmural drainage over the past 8 years was done to identify patients with DPDS and indwelling transmural stents for >3 years. Results: During the past 8 years, 56 patients with indwelling transmural stent for >3 years were identified and 67.85% of these patients had 10 Fr stents and 32.15% of patients had 7 Fr stents. On follow-up, 5 (8.9%) patients had pancreatic pain with one patient (1.78%) developing recurrence of PFC despite stent being in situ. Two (3.5%) patients had asymptomatic spontaneous external migration of the transmural stent. Fourteen (25%) patients developed diabetes. Two (3.5%) patients developed local complications due to indwelling stent (stent eroded into descending colon in one patient and stent-induced parenchymal calcification in the other). Forty-eight (85.7%) patients underwent EUS on follow-up and disconnected pancreas revealed ≥5 criteria for the diagnosis of chronic pancreatitis in 15 (31.25%) patients. Conclusions: Long-term indwelling transmural plastic stents in patients with WON and DPDS are safe and effective with minimal complications. Despite the presence of stents, disconnected pancreas develops morphological changes resembling chronic pancreatitis in one-third patients and clinical consequences of these changes need to be further evaluated.

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Background and Objective: EUS-FNA sensitivity for malignancy in parenchymal masses of patients with concurrent chronic pancreatitis (CP) has been reported to be unsatisfactory. The aim of the present study was to directly compare the diagnostic accuracy of EUS-FNA and EUS-fine-needle biopsy (FNB) in differentiating between inflammatory masses and malignancies in the setting of CP. Methods: We performed a retrospective analysis of prospective, multicentric databases of all patients with pancreatic masses and clinico-radiological-endosonographic features of CP who underwent EUS-FNA or FNB. Results: Among 1124 patients with CP, 210 patients (60% males, mean age: 62.7 years) with CP and pancreatic masses met the inclusion criteria and were enrolled. In the FNA group (110 patients), a correct diagnosis was obtained in all but 18 cases (diagnostic accuracy 83.6%, sensitivity 69.5%, specificity 100%, positive predictive value [PPV] 100%, and negative predictive value [NPV] 73.9%); by contrast, among 100 patients undergoing FNB, a correct diagnosis was obtained in all but seven cases (diagnostic accuracy 93%, sensitivity 86.8%, specificity 100%, PPV 100%, and NPV 87%) (P = 0.03, 0.03, 1, 1, and 0.07, respectively). At binary logistic regression, focal pancreatitis (odds of event occurrence [OR]: 4.9; P < 0.001), higher Ca19-9 (OR: 2.3;P= 0.02), and FNB (OR: 2.5; P < 0.01) were the only independent factors associated with a correct diagnosis. Conclusion: EUS-FNB is effective in the differential diagnosis between pseudotumoral masses and solid neoplasms in CP, showing higher diagnostic accuracy and sensitivity than EUS-FNA. EUS-FNB should be considered the preferred diagnostic technique for diagnosing cancer in the setting of CP.

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Benign or malignant conditions can present as pancreatic solid lesions (PSLs), and a thorough diagnostic workup is necessary to differentiate them. The need to acquire a tissue sample to reach a definitive diagnosis should be stratified by the findings at multidetector computed tomography (MDCT) with a pancreatic protocol. Tissue biopsy is currently indicated in patients fit for chemotherapy in whom a metastatic tumor or a locally advanced unresectable lesion are discovered. For these patients, EUS-guided tissue acquisition, with fine-needle aspiration (FNA) or biopsy represents the gold standard to provide a definitive cyto- and/or histopathologic diagnosis, with a high rate of accuracy. For resectable PSLs with a nonhypoenhancing MDCT pattern, which is not disease specific, a tissue diagnosis to distinguish benign from malignant etiologies appears mandatory. On the other hand, for hypo-enhancing PSLs, the debate of whether to obtain a preoperative definitive diagnosis still favors direct surgery. However, availability of novel EUS-guided fine-needle biopsy needles, which can ameliorate the negative predictive value of EUS-FNA and allow performance of DNA and RNA whole-genome extraction and RNA sequencing, coupled with the increasing evidence that preoperative neoadjuvant chemotherapy can be of value for these patients may change completely the diagnostic and therapeutic approach to resectable PSLs. These recent breakthroughs suggest the need for a new multidisciplinary consensus meeting to integrate them into the decision-making process assessing the need for preoperative tissue diagnosis in resectable PSLs.

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