Introduction

Acute pancreatitis (AP) is closely intricately linked to electrolyte disturbances. Such imbalances can exacerbate the instability of the intracellular environment, subsequently accelerating the progression of AP. This study aimed primarily to develop a simplified electrolyte scoring system (CC score) to determine AP exacerbation.

Aims & Methods

A new CC score was established in this study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) v3.1 database, and it was validated using the digestive department database of the First Affiliated Hospital of Nanchang University. The primary endpoint considered was the exacerbation of the disease post-admission in AP patients. Receiver operating characteristic (ROC) curves and decision curve analysis (DCA) plots were used to assess the predictive value and clinical applicability of the new CC score. Improvements were implemented on the acute physiology and chronic health evaluation II (APACHE II) and systemic inflammatory response syndrome (SIRS) scoring systems, and their performance was compared with that of traditional predictive scoring systems.

Results

This study incorporates data from 1413 AP patients drawn from the MIMIC-IV database, supplemented by a further 1040 AP patients in an external validation group. Of these, 178 and 70 AP patients were respectively transferred to the Intensive Care Unit (ICU). The multivariate adjustment model indicates that a significant negative correlation between serum Ca²⁺ levels and severe progression in AP patients, while serum Cl^- levels showed a J-shaped association with severe progression. Through node analysis of the restricted cubic splines (RCS) model, combined with the clinical grading standards for hyperchloremia and hypocalcemia, the critical values for Cl^- and Ca²⁺ were determined to be 110 mmol/L and 1.77 and 2.1 mmol/L, respectively. Based on these findings, we established a new CC score and optimized the APACHE II and SIRS scoring systems. The results indicated that the predictive power of the optimized APACHE II score (AUC=0.83) and SIRS score (AUC=0.87) for severe progression in AP patients surpassed that of the original APACHE II score (AUC=0.74) and SIRS score (AUC=0.71).

Conclusion

The new CC score not only effectively predicts the risk of severe progression in AP patients but also enhances the predictive performance of both SIRS and APACHE II scores for assessing severe progression risk in these patients.

Introduction

Pancreatic cystic lesions (PCLs) are common and could vary from a simple benign cyst to a highly malignant cyst.¹ Mixed lesions with a solid part and a cystic part are very uncommon. They could be a sign of malignant transformation of a cyst.² Recently the awareness of these lesions has increased, especially with the increased incidence of asymptomatic pancreatic cysts worldwide primarily due to improved detection by different advanced imaging modalities.³Therefore, the proper diagnosis, differentiation and staging of these lesions are crucial for proper management and avoiding unnecessary treatment of benign ones and missing early treatment of the pre-malignant lesions.⁴ EUS-guided fine needle biopsy (EUS-FNB) may overcome these limitations of EUS-FNA through acquisition of core tissue samples that provide the ability to assess cyst wall architecture via histology. At this point, ESGE does not recommand use of EUS-FNB for diagnosis of cystic lesions.⁵

Aims & Methods

Aim: Based to the literature, there are few reports regarding the role of EUS-FNB replacing EUS-FNA in the diagnosis of PCL. This work aims to study the feasibility and safety of EUS-FNB 22G in diagnosis of PCLs.
Methods: Of 640 consecutive EUS-FNB 22G for different lesions between January,2019 and December,2023 at our center. 60 EUS-FNB 22G were done for the patients who underwent EUS-guided sampling of pancreatic cystic or mixed lesions diagnosed by abdominal MRI and/or CT scan. The patients were retrospectively and prospectively followed. All the solid lesions, pancreatic pseudocysts (round, non-septated lesions, presence of internal debris, recent acute pancreatitis or radiologic imaging of chronic pancreatitis) and lesions interposed vessels or main pancreatic duct are excluded from this study.Patients with history of severe hemorrhagic risk (platelet count <50,000 /Lor prothrombin activity <50%) are excluded. We statistically analyse the clinical and technical success rates, in addition to evaluate the diagnostic accuracy of EUS-FNB in differentiating benign and malignant pancreatic cystic lesions. Evaluation of the cyst location, primary diagnosis, adverse events, and comparison between the cytologic fluid analyses and histopathology was performed. Technical success was defined as visible tissue present after biopsy. Clinical success was defined as the presence of a specimen adequate to make a histologic or cytologic diagnosis.

Results

A total of 60 patients (mean age 65.0 ± 12.1, 36.6% females) with 60 PCLs consecutively were referred for EUS-FNB 22G and enrolled in a prospective study. 41/60 (68.3%) lesions were mixed (cystic and tissue) and 19/60 (31.7%) lesions are cystic lesions. The mean lesion size was 32.4 ± 16.6mm. The EUS-FNB 22G procedure was technically and clinically successful in all patients (100%). The mean number of needle passes, as defined as unique transluminal needle insertions into the cystic compartment, was 1.9 ± 0.6. No immediate adverse events were developed after the procedure. In 57/60 (95.0%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. Among the 10 patients who had surgical teatment, the concordance of FNB compared to surgical pathology was noticed.

Conclusion

The diagnosis of pancreatic cystic and mixed lesions with a solid and liquid component can be achieved with fine needle biopsy using a 22-gauge needle in a safe and practicable manner. This method has a great diagnostic yield and does not increase the rate of complications.

References

1. Basturk O, Coban I, Adsay NV. Pancreatic cysts: pathologic classification, differential diagnosis, and clinical implications. Arch Pathol Lab Med. 2009;133:423–438.
2.Da Silva RJ, Oliveira INF, Ribeiro TC da R, Chebli LA, Pace FH de L, Chebli JMF. A Rare Presentation of a Solid Pseudopapillary Neoplasm of the Pancreas. GE Port J Gastroenterol. mars 2022;29(2):135‑8.
3. De Jong K, Bruno MJ, Fockens P. Epidemiology, diagnosis, and management of cystic lesions of the pancreas. Gastroenterol Res Pract. 2012;2012:147465.
4. Okasha H, E Behiry M, Ramadan N, Ezzat R, Yamany A, El-Kholi S, Ahmed G. Endoscopic ultrasound-guided fine needle aspiration in diagnosis of cystic pancreatic lesions. Arab J Gastroenterol. 2019;20:86–90.
5.Polkowski M, Jenssen C, Kaye P, Carrara S, Deprez P, Gines A, et al. Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline - March 2017. Endoscopy. oct 2017;49(10):989‑1006.

Introduction

Pancreatic pseudocysts (PPs), common complications of acute or chronic pancreatitis, are often managed with endoscopic ultrasound-guided double pigtail stent (EUS-DPS) drainage. However, the relationship between stent indwelling duration and PPs recurrence remains poorly defined.

Aims & Methods

We aimed to investigate whether shorter stent dwelling duration is associated with a higher risk of PPs recurrence. Patients diagnosed with PPs who underwent EUS-DPS drainage at Peking Union Medical College Hospital between June 2006 and December 2024 were retrospectively reviewed. Clinical outcomes including technical success, clinical success, postoperative complications, and recurrence were analyzed. Furtherly, the stent indwelling duration-recurrence relationship and risk factors were evaluated.

Results

A total of 116 patients were included (84 males, 72.4%), with a mean age of 48.29±13.56 years. The most common etiologies were biliary pancreatitis (28.4%) and alcoholic pancreatitis (25.9%). PPs were primarily located in the pancreatic body and tail (78.4%), with a mean diameter of 10.23±4.17 cm. Regarding drainage success, technical success was achieved in 106 cases (91.4%), and clinical success in 81 cases (69.8%). Postoperative adverse events occurred in 33.6% of patients, including infections (n=31), bleeding (n=3), perforation (n=2), and cardiopulmonary events (n=3). Patients with clinical success were stratified by stent indwelling duration (0-2 months, 2-6 months, >6 months), while PPs recurrence was significantly higher in the short-duration group compared to the intermediate- and long-duration groups (p-value < 0.05). No postoperative adverse events occurred beyond 30 days in any group, suggesting that prolonged stent indwelling duration does not increase the risk of long-term complications. Meanwhile, multivariate regression analysis identified longer stent dwelling duration and elevated high-sensitivity C-reactive protein as independent protective factors for clinical success.

Conclusion

EUS-DPS placement represents a safe and effective modality for internal drainage and therapeutic approach for PPs. Our findings support that maintaining stent placement for more than six months to significantly reduce recurrence risk and improve long-term clinical outcomes, with manageable adverse events.

Introduction

The optimal management of small (≤2 cm) low-grade pancreatic neuroendocrine neoplasms (PNENs) remains a subject of ongoing debate. While surgical resection has traditionally been the standard treatment, its invasiveness and potential for long-term complications, such as pancreatic insufficiency, have driven interest in less invasive alternatives. Recently, endoscopic ultrasonography-guided ethanol injection (EUS-EI) has emerged as a promising treatment option, offering the potential for localized tumor control with minimal impact on surrounding pancreatic tissue.

Aims & Methods

This study was conducted at a single academic center between 2014 and 2024, and the data were retrospectively analyzed. Eligibility criteria included patients with pathologically confirmed grade 1 PNENs ≤2 cm who were either poor surgical candidates or declined surgery. The procedure was carefully planned to minimize complications and improve treatment outcomes. A 25-gauge needle was used to reduce the risk of ethanol leakage. Pure ethanol was injected under EUS guidance until hyperechoic bubbles fully surrounded the tumor margin. To ensure complete coverage while minimizing ethanol exposure, ethanol was injected from multiple sites if needed. Importantly, the maximum ethanol volume per session was limited to 2 mL to prevent overexposure and reduce adverse events. To optimize treatment efficacy, contrast-enhanced computed tomography (CE-CT) was performed on postoperative day 3. If residual enhancement was detected, an additional ablation session was scheduled during the same hospitalization, allowing for planned, staged treatment.

Results

A total of 41 patients including four patients with insulinoma underwent EUS-EI, The median tumor size of 10 mm (range: 6–15 mm). The median ethanol volume in the initial session was 0.9 mL (range: 0.3–2.0 mL), and the total median volume was 1.0 mL (range: 0.3–3.2 mL), reflecting the effectiveness of carefully distributed, low-volume injections. Fifteen patients (37%) required an additional planned ablation session based on CE-CT findings. Mild pancreatitis occurred in 6 patients (14%), and the median hospital stay was 5 days (range: 4–8 days), suggesting a favorable safety profile. Complete ablation was confirmed in 37 patients (90%) at one month post-procedure. All patients with insulinomas experienced an improvement in hypoglycemia-related symptoms. During a median follow-up of 36 months, local recurrence was observed in only 2 patients (5%), occurring at 22 and 51 months, respectively. Notably, no cases of new-onset diabetes mellitus were reported.

Conclusion

Planned, staged EUS-guided ethanol injection using low per-session ethanol volumes is a safe and effective treatment strategy for patients with small, low-grade PNENs. This approach appears to reduce procedure-related complications while enhancing the rate of complete tumor ablation.

References

Matsumoto K, Kato H, Itoi T et al. Efficacy and safety of endoscopic ultrasonography-guided ethanol injections of small pancreatic neuroendocrine neoplasms: a prospective multicenter study. Endoscopy. 2025 Apr;57(4):321-329. doi: 10.1055/a-2452-4607. Epub 2024 Oct 25. PMID: 39454635; PMCID: PMC11997695.

Introduction

IgG4-related disease (IgG4-RD) is a chronic fibro-inflammatory multi-systemic disease. Pancreato-biliary involvement is reported in up to 60%, which can lead to exocrine and endocrine pancreatic insufficiency. Glucocorticoids can be used to control active inflammation but are associated with substantial toxicity. B-cell depletion with anti-CD20 chimeric Rituximab (RTX) and anti-CD19 humanised Inebilizumab (INEB) are steroid-sparing and used to control disease flares. INEB is the only FDA-approved medication for the treatment of IgG4-RD.

Aims & Methods

Our aim was to compare B-cell depleting agents for the treatment of IgG4-RD. We searched PubMed, Cochrane Central Register of Clinical Trials and Embase databases for studies of maintenance therapy in IgG4-RD with a pre-defined strategy and performed a network meta-analysis to assess relapse at 12 months, occurrence of infections and infusion-related reactions.

Results

96 out of 2545 manuscripts underwent full text review after exclusions. Three studies met eligibility for the meta-analysis, two reporting the use of RTX and one of INEB (Table 1).

For the primary outcome of disease relapse at 12 months, INEB had a risk ratio (RR) of 5.8 (95% CI 0.29 - 115.02) and RTX had an RR of 2.29 (95% CI 0.19 - 28.21), with INEB being superior in preventing relapses. The RR for infections with INEB was 0.81 (95% CI 0.19 - 3.41) whilst with RTX was 0.62 (95% CI 0.13 - 3.04). The RR for infusion-related reactions with INEB was 1.27 (95% CI 0.09 - 18.76) and for RTX was 0.93 (95% CI 0.11 - 8.19). These must be interpreted in the context of study design; INEB in a phase 3 randomised trial following a stringent safety protocol for reporting of adverse events, and RTX in retrospective observational studies.

Conclusion

This Network Meta-analysis demonstrates that INEB is superior to RTX at preventing disease relapses in patients with IgG4-RD at 12 months. Adverse events, such as infection and infusion-related reactions, were comparable in lieu of the methodological differences between studies.

Disclosure

Emma L Culver has received speaker fees from Albireo/IPSEN, Advanz/Intercept, Dr Falk, Amgen, GSK, Mirum Pharma, Gilead, Chemomab, Zenus Bio, and Advisory/consultancy fees from Advanz/Intercept, IPSEN, Mirum, GSK, Dr Falk Pharma, Amgen, Zenus Bio, Sanofi, Moderna and Sail BioPharma. MC has received speaker fees from Albireo/IPSEN, Advanz/Intercept, Amgen, GSK, Mirum Pharma, Gilead, and Advisory/consultancy fees from Advanz/Intercept, Alphasigma, Albireo/IPSEN, Mirum, GSK, Dr Falk Pharma, Amgen, Mayoly, Echosens, Kowa, Moderna, Zydus.

Introduction

Differentiating mucinous (MPCLs) from non-mucinous pancreatic cystic lesions (NMPCLs) remains critical for appropriate therapeutic decisions. While carcinoembryonic antigen (CEA) levels >192 ng/mL have been the conventional benchmark, their limited sensitivity underscores the need for more accurate alternatives. Recent data suggest intracystic glucose levels may be a promising biomarker. This study prospectively evaluated the diagnostic performance of intracystic glucose compared to CEA in pancreatic cyst fluid obtained via EUS-guided fine needle aspiration (EUS-FNA).

Aims & Methods

From July 2018 to October 2024, 24 patients with pancreatic cystic lesions undergoing EUS-FNA using a 22G needle were included. Glucose and CEA concentrations were measured using standard biochemical protocols. Final diagnosis was based on surgical pathology (n=5), cytopathology (n=9), or consensus radiologic/endoscopic evaluation by two blinded expert pancreatologists (n=10). All procedures and analyses were performed in a tertiary academic gastroenterology center in Morocco.

Results

Mean patient age was 59.8 years. Diagnoses comprised 13 mucinous cysts (54.2%; including 9 IPMNs and 4 MCNs), 7 serous cystadenomas (29.2%), 2 cystic neuroendocrine tumors (8.3%), 1 pseudocyst, and 1 simple cyst.
The mean intracystic glucose level in MPCLs was 14.1 mg/dL (95% CI: 5.6–22.6), versus 90.3 mg/dL (95% CI: 82.1–98.6) in NMPCLs (p < 0.0001). A glucose threshold of ≤30 mg/dL yielded an AUC of 0.94 (95% CI: 0.84–0.99), with 92.3% sensitivity and 100% specificity.
For CEA ≥192 ng/mL, AUC was 0.71 (95% CI: 0.54–0.86), with 46.1% sensitivity and 100% specificity. No significant correlation was found between glucose levels and either CEA or cyst size.

Conclusion

Intracystic glucose represents a simple, cost-effective, and highly accurate marker for distinguishing mucinous from non-mucinous pancreatic cystic lesions. It demonstrates superior sensitivity compared to CEA and can be a valuable adjunct in the diagnostic algorithm of pancreatic cysts, particularly in resource-conscious settings.

References

 Carrara S, Ceriello A, Arcidiacono PG. Glucose in pancreatic cyst fluid: a reliable test for mucinous cysts? Endoscopy. 2022;54(1):63–70.
 Köker D, Tevethia H, Madhoun MF. Intracystic glucose: a promising low-cost tool in differentiating pancreatic cysts. Gastrointest Endosc. 2023;97(4):832–9.
 Alomari F, Hammad T, Khasawneh MA, et al. Diagnostic performance of EUS-FNA glucose vs CEA in pancreatic cysts. Pancreas. 2021;50(5):661–6.

Introduction

Patients with suspected main-duct intraductal papillary mucinous neoplasms (MD-IPMN) are frequently referred for surgery due to the high risk of malignancy (as high as 40% to 60% in the literature). However, many present with significant comorbidities or concurrent malignancies, complicating the surgical risk-benefit assessment. In such cases, advanced endoscopic procedures may assist in guiding clinical decision-making.

Aims & Methods

This study aimed to evaluate the role of EUS-guided fine-needle biopsy (EUS-FNB) and pancreatoscopy in individualized risk stratification and management decisions for patients with suspected MD-IPMN. We retrospectively analyzed eight patients treated at our center between March 2020 and March 2025. All patients presented with significant comorbidities or active oncologic disease. Data collected included endoscopic findings, biopsy results, complications, and final management decisions.

Results

Eight patients with suspected main-duct IPMN were included (mean age: 67.6 years; 3 females, 37.5%). The mean main pancreatic duct (MPD) diameter was 9.1 mm. All patients were evaluated in a multidisciplinary setting due to clinical complexity, including comorbidities or concurrent malignancies. EUS-guided fine-needle biopsy (EUS-FNB) was performed in 3 patients, and pancreatoscopy in 5. All procedures were technically successful. Biopsy samples were diagnostic in 2 of 3 EUS-FNB cases and 5 of 5 pancreatoscopy cases and contributed directly to management decisions. In 1 EUS-FNB case, the sample was non-diagnostic. Pancreatoscopy revealed mucin extrusion in 4/5 patients, papillary or villous projections in 3/5, and a 'fish egg' appearance in 2/5. These features supported risk assessment and, in several cases, justified a conservative approach in high-risk patients. Three patients underwent surgery following multidisciplinary review. One had concordant findings (high-grade dysplasia), while two had discordant outcomes: one with low-risk pancreatoscopy findings had invasive adenocarcinoma, and one with EUS-FNB showing low-grade atypia had high-grade dysplasia on final pathology. Five patients were managed with active surveillance. One case of mild post-ERCP pancreatitis occurred; no other complications were reported. Endoscopic findings influenced management in 5 of 8 patients (62.5%).

Conclusion

In this real-world case series, EUS-FNB and pancreatoscopy contributed meaningfully to individualized decision-making in patients with suspected MD-IPMN. However, discordance between endoscopic impressions and final pathology in two cases highlights the limitations of visual and cytologic assessment. These findings reinforce the need for integrating endoscopic data with imaging, clinical context, and multidisciplinary input when evaluating main-duct IPMN.

References

1. Salvia R, Fernández-del Castillo C, Bassi C, Thayer SP, Falconi M, Mantovani W, Pederzoli P, Warshaw AL. Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg. 2004 May;239(5):678-85; discussion 685-7. doi: 10.1097/01.sla.0000124386.54496.15. PMID: 15082972; PMCID: PMC1356276.
2. Sohn TA, Yeo CJ, Cameron JL, Hruban RH, Fukushima N, Campbell KA, Lillemoe KD. Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg. 2004 Jun;239(6):788-97; discussion 797-9. doi: 10.1097/01.sla.0000128306.90650.aa. PMID: 15166958; PMCID: PMC1356287.