Introduction

In the late stage of acute pancreatitis, the occurrence of pancreatic walled-off necrosis (WON) can be life-threatening, especially in the presence of infection. EUS-guided transgastric drainage is currently a minimally invasive treatment modality for the clinical treatment of WON. However, there is no consensus in international guidelines on the choice between lumen-apposing metal stents (LAMS) and traditional double-pigtail plastic stents (DPT).

Aims & Methods

Objective To investigate the differences in drainage effectiveness and complications among different stents, we included currently published randomized controlled trials (RCTs) for a meta-analysis. Methods We systematically searched the PubMed, Embase, and Cochrane Library databases for studies published between 1 January 2010 to 1 March 2023, and updated the search on March 1, 2025. The observed indicators included: primary outcome indicators (clinical success rate, re-intervention), other observation indicators (total adverse events, mortality, adverse events, procedural duration). Binary variables were analyzed using relative risk (RR) and 95% CI, while continuous variables were analyzed using mean difference (MD). The selection of a random effects model or fixed effects model depended on the situation.

Results

Six RCTs with a total of 325 patients were included for analysis, with 177 patients in the LAMS group and 175 patients in the DPT group. There was similar in the primary outcome indicators of clinical success rate (RR=1.05; 95% CI 0.93 - 1.17; P=0.46), the number of patients requiring debridement of necrotic tissue (RR=0.95; 95% CI 0.62 - 1.47; P=0.83), and percutaneous drainage (RR=0.98; 95% CI 0.27 - 3.5; P=0.97). There were also no significant differences in terms of mortality rate (RR=0.86; 95% CI 0.32 - 2.33; P=0.77), total adverse events (RR=0.87; 95% CI 0.59 - 1.29; P=0.48), adverse events related to bleeding (RR=1.48; 95% CI 0.67 - 3.28; P=0.34), procedural time (MD=-9.44; 95% CI, -15.27 - -3.61, P=0.002).

Conclusion

In comparison to DPT, LAMS could shorten procedural duration. However, there was no significant difference clinical success rate, re-intervention and adverse events. Therefore, future studies with large samples and high quality are needed for further confirmation. Meanwhile, due to the high heterogeneity among studies, conclusions should be considered with caution. Clinicians need to make the most suitable treatment decisions based on the actual situation to ensure patients get the best treatment effect and prognosis.

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

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.

Introduction

Pancreatic steatosis (PS) is linked to metabolic dysregulation. Magnetic resonance imaging (MRI)-derived proton density fat fraction (PDFF) provides a reliable assessment of intrapancreatic fat. This study investigates the relationship between pancreatic fat, assessed by ultrasound and MRI, and metabolic parameters from the oral glucose tolerance test (OGTT).

Aims & Methods

We analyzed 40 non-diabetic patients with increased pancreatic echogenicity, of whom 29 completed the study (mean age: 54 ± 10.4 years; BMI: 34.8 kg/m²; waist circumference: 93.8 ± 11.3 cm). Participants underwent OGTT, with assessment of β-cell function indices (Disposition Index, Insulinogenic Index) and insulin sensitivity indices (Matsuda Index, HOMA-IR, Stumvoll Index). Pancreatic fat was evaluated using ultrasound, MRI-PDFF, and two-dimensional shear wave elastography.

Results

The mean pancreatic fat fraction was 13.75 ± 11.22% (median: 7.633%), and mean pancreatic stiffness was 8.1 ± 3.2 kPa. After OGTT, 27.5% of patients exhibited impaired glucose tolerance (IGT). PDFF positively correlated with weight (r = 0.520, p = 0.004), BMI (r = 0.505, p = 0.005), and body surface area (r = 0.509, p = 0.005), but not with liver enzymes, metabolic parameters, or β-cell function. A significant negative correlation was found between pancreatic stiffness and the Potentiation Factor (PFR1), indicating reduced β-cell responsiveness with increasing pancreatic stiffness. Stratification by glucose tolerance status revealed that increased pancreatic fat was associated with greater insulin resistance and compensatory hyperinsulinemia.

Conclusion

In conclusion, our study confirms that increased intrapancreatic fat is an indicator of ectopic lipid accumulation and is correlated with general adiposity. Our study identifies pancreatic fat infiltration as a marker of early metabolic dysfunction, where increasing pancreatic fat triggers β-cell compensatory mechanisms. This underscores the importance of determining a pancreatic fat threshold below which glucose homeostasis may still be restored. Targeted interventions to reduce pancreatic fat are crucial to preventing the progression to irreversible β-cell dysfunction.

Introduction

Pancreatic calcification is the most frequent structural change in chronic pancreatitis (CP), but the factors associated with its development are not well understood.

Aims & Methods

We aimed to investigate the risk factors of calcification development in patients with chronic pancreatitis. The study protocol was registered on PROSPERO (CRD42024591837). On September 18, 2024, we conducted a systematic search across three databases (PubMed, EMBASE, and CENTRAL) for studies reporting factors associated with calcification in chronic pancreatitis (CP). Pooled proportions and odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effects model.

Results

The systematic search resulted in 10,893 articles, from which 85 eligible studies were identified, covering a total of 34568 participants. The odds of calcification were 45% higher in alcoholic compared to idiopathic CP (OR=1.45, CI: 1.00–2.11). Alcohol consumption (OR=2.31, CI: 1.8–2.98) and smoking (OR=2.22, CI: 1.61–3.06) were associated with a two times higher risk of calcification in CP, when compared to non-smokers and non-drinkers. In contrast, the presence of CFTR mutations did not increase the risk of calcification in CP (OR=0.43, CI: 0.11–1.66) compared to patients without CFTR mutations.

Conclusion

Alcohol consumption and smoking were significantly associated with the presence of calcification in CP, making it essential to identify these risk factors and incorporate smoking cessation and alcohol reduction programs into standard care.

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.