Introduction

The learning curve for EUS-guided Gastroenterostomy (EUS-GE) has been assessed through retrospective studies involving few elite senior endoscopists (SE), using procedural time as the main surrogate outcome. This study aims to evaluate the training course of junior endoscopists (JE) approaching EUS-GE using the WEST technique, considering both technical efficiency and clinically relevant patient outcomes.

Aims & Methods

From a prospective single-centre registry of EUS-GE (PROTECT, ClinicalTrials.gov NCT04813055) using the Wireless Simplified Technique (WEST), the learning curve of 3 JE, experienced in pancreatobiliary endoscopy (PBE) was analysed to identify inflection points (“knots”), applying adaptive regression and cumulative sum control chart (CUSUM) on several continuous and dichotomous variables. EUS-GE performed by a SE and those on post-surgical anatomy were excluded.

Results

From a prospective database of 165 EUS-GE, 100 were performed by a JE with previous EUS-GE training (JE1) and 26 by two naïve JEs.
In JE1’s curve, neither procedural nor fluoroscopy time showed any improvement while radiation dose (mean Air Kerma: 392 ± 317 Gy) significantly decreased (F-test p=.0005) after 57 (adaptive regression) and 72 interventions (CUSUM), stabilizing thereafter. The need for supervision/backup from a SE showed a significant knot after 32 procedures (p<.0001). Technical success (100%), clinical success (95.0%), adverse events (AEs; 6.0%) and moderate/severe AEs (4.0%) remained constant through the learning curve, clustered according to the aforementioned knots. Conversion from EUS-GE to enteral stenting was rare (7.2%) and non-significantly decreased over time.
Despite requiring significantly higher fluoroscopy time (234 vs. 187 seconds, p=.009) and procedural time (55 vs. 43 minutes, p=.002), naïve endoscopists achieved efficacy and safety outcomes comparable to the remaining cohort.

Conclusion

From the analysis of a prospective learning curve, performing ≈ 30 EUS-GE seems required for independent practice, and ≈ 70 to stabilize the fluoroscopy usage. EUS-GE training of naïve PBE endoscopists in high-volume institutions, using a standardized technique, does not compromise clinical and safety standards.

Introduction

The aetiology of acute pancreatitis remains elusive in 10-30% of patients after clinical, biological and morphological investigations. Endoscopic ultrasound has shown promise and is particularly effective in exploring the bilio-pancreatic region.

Aims & Methods

The aim of our study was to evaluate the contribution of endoscopic ultrasound to the aetiological diagnosis of unexplained acute pancreatitis.
This is a retrospective descriptive study of 89 patients who underwent endoscopic ultra sound for unexplained acute pancreatitis between January 2010 and January 2025.

Results

The mean age of our patients was 55 +/- 16.3 years, with extremes ranging from 17 to 89 years. The sex ratio (M/F) was 0.81, with a slight female predominance of 55.1%. A history of previous acute pancreatitis was found in 31.9% of cases, and 16.3% of patients had undergone cholecystectomy. The diagnostic yield in our study was 68%. Biliary origin was retained in 40.4% (n=36) of patients, 19 of whom underwent complementary ERCP at the same anaesthetic time. Neoplastic pathology was found in 32.5% of cases (n=30). Chronic pancreatitis was reported in 22.4% of patients (n=20). Two cases of pancreas divisum, one case of sphincter of Oddi dysfunction and one case of choledocele were found. In the remaining 32% of cases, the endoscopic ultrasound was normal and no cause could be found.

Conclusion

Endoscopic ultrasound is currently an indispensable tool in the etiological investigation of unexplained acute pancreatitis. In our study, the diagnostic efficiency was around 68%.

Introduction

Cholecystectomy is recommended for patients with acute biliary pancreatitis to prevent recurrence and other biliary complications. However, some patients, due to advanced age and comorbidities, are unfit for surgery. The role of endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) in these cases is not well established^1,2.

Aims & Methods

We aimed to evaluate whether ES reduces the risk of recurrent biliary pancreatitis (RBP) in patients unfit for cholecystectomy.
A unicentric retrospective review was conducted including all patients admitted for a first episode of acute biliary pancreatitis between January 2016 and November 2023 at a non-tertiary hospital, who were deemed unfit for cholecystectomy by either surgical or anesthetic teams. Patients with concurrent acute cholangitis at admission or during hospitalization, as well as those with prior cholecystectomy or ES, were excluded. Time-to-event analysis was performed using Kaplan-Meier survival curves.

Results

A total of 169 patients were included, with a mean age of 79.07 ± 8.25 years, and 65% were female. The mean Charlson Comorbidity Index was 5.11 ± 2.09. Most cases (94%) presented as mild or moderately severe pancreatitis. The mean follow-up period was 3.80 ± 1.95 years.
During the index admission, 37% (n=62) underwent ERCP with ES.
Recurrent biliary pancreatitis (RBP) occurred in 35 patients (21%), 97% of whom had not undergone ES. Only one patient in the ES group was readmitted for a new episode of pancreatitis (p<0.001, OR 0.035; 95% CI 0.005–0.265). The mean time to recurrence was 2.67 ± 7.78 months. Kaplan-Meier survival analysis demonstrated a significantly lower cumulative incidence of RBP in the ES group (log-rank p<0.001).
Endoscopic sphincterotomy did not significantly reduce other biliary events, including choledocholithiasis, acute cholangitis, and acute cholecystitis (all p>0.05). There was no statistically significant difference in overall mortality between the two groups (p=0.585).

	Overall (n=169)	No intervention (n=107)	ERCP + ES (n=62)	p value
Recurrent biliary pancreatitis	21% (n=35)	32% (n=34)	2% (n=1)	p<0.001
Choledocholithiasis	3% (n=5)	4% (n=4)	2% (n=1)	p=0.653
Acute cholangitis	2% (n=4)	3% (n=3)	2% (n=1)	p=1
Acute cholecystitis	7% (n=11)	4% (n=4)	2% (n=1)	p=0.101
Overall mortality	25% (n=43)	27% (n=29)	23% (n=14)	p=0.585

Conclusion

Our findings suggest that ERCP with ES may effectively reduce the recurrence of gallstone pancreatitis in elderly patients with high surgical-anesthetic risk due to comorbidities. Further studies are needed to refine the selection criteria for these patients.

References

1 - Hwang SS, Li BH, Haigh PI. Gallstone pancreatitis without cholecystectomy. JAMA Surg. 2013 Sep;148(9):867-72.
2 - McAlister, V., Davenport, E., & Renouf, E. (2007). Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database of Systematic Reviews.

Introduction

The revised Atlanta Classification delineates the local complications of acute pancreatitis, categorizing them as acute (peri)pancreatic fluid collections (PFCs), acute necrotic collections, pancreatic pseudocysts, and walled-off pancreatic necrosis (WOPN). Various endoscopic interventions are employed for the management of WOPN, notably including direct transluminal endoscopic necrosectomy (DEN) following the placement of an endoscopic ultrasound-guided (EUS) lumen-apposing metal stent (LAMS). This study aims to assess the clinical outcomes and safety profile of DEN in patients diagnosed with pancreatic WOPN.

Aims & Methods

This single-center retrospective analysis encompasses patients with pancreatic WOPN who underwent DEN at Semmelweis University between October 1, 2021, and October 1, 2024. The procedures were performed by three seasoned specialists in EUS and endoscopic retrograde cholangiopancreatography (ERCP). Comprehensive data on patient demographics, procedural specifics, and follow-up outcomes were collected, with adverse events classified according to the AGREE criteria.

Results

We successfully placed LAMS in 31 patients (61% female, mean age 66.3 years, SD 9.4). The primary indications for intervention included the dimensions of WOPN, exacerbation of gastric outlet obstruction, and signs of infection. The mean dimensions of WOPN were recorded as 98 mm in the anteroposterior direction (SD 35.6), 90 mm laterolateral (SD 44), and 88 mm craniocaudal (SD 27.4), with a predominant occurrence in the head of the pancreas (60%). Alcohol consumption emerged as the leading etiological factor for WOPN in 92% of male patients, whereas biliary causes were identified in 67% of female patients.
In total, we conducted 83 DEN procedures across the 31 patients (51 males and 32 females). The average number of DEN sessions was three for both male and female groups (range: 2-6). The technical success rate achieved was 100%, accompanied by a clinical success rate of 97%. One patient succumbed to the condition; however, three of the surviving 30 required intensive care due to multiorgan failure. To enhance the resolution of infection between DEN sessions, we employed 7 Fr/250 cm nasocystic tubes for irrigation of the WOPN with a saline solution in all patients, with no adverse events reported as a result of this intervention.

Conclusion

DEN can be performed safely in experienced medical centers and demonstrates a high success rate in the treatment of infected WOPN, effectively alleviating symptoms and decreasing enzyme levels. The predominant etiology of WOPN formation in male patients is attributed to alcohol consumption, while biliary factors are more prevalent in female patients.

Introduction

While pancreatic cancer is traditionally associated with older age, its incidence is rising in adults under 50. This younger population often falls outside standard screening and triage pathways, contributing to delayed diagnosis. In the absence of risk factors, early symptoms may be overlooked or misattributed, delaying imaging and leading to advanced-stage discovery. Although a minority of patients carry hereditary risk, the majority of young cases present without identifiable predispositions.

Aims & Methods

This study aimed to describe the clinical, biological, and diagnostic profile of pancreatic cancer in adults under 50, with a focus on diagnostic delays, tumor marker levels, disease stage, and the presence of traditional risk factors.
A retrospective monocentric analysis was conducted on all patients diagnosed with pancreatic cancer between January 2020 and December 2024 at a regional reference center. Patients were divided into two age groups: <50 and ≥50 years. Variables included age, sex, BMI, smoking status, diabetes, CA 19-9 levels, time from symptom onset to diagnosis, and tumor stage (resectable, borderline, locally advanced, metastatic). Statistical analyses used chi-square and non-parametric tests.

Results

Among 293 patients, 24 (8.2%) were under 50 years (range: 31–49; median age: 46.5 years).

• This younger group had a male predominance (62%) and lower median BMI (22.3 kg/m²).
• Diagnostic delays >30 days were more frequent in younger patients (71%) vs. older adults (56%) (p = 0.04), with a longer median delay (45 vs. 35 days).
• Median CA 19-9 was higher in the younger group (970 vs. 503 U/mL), and values >1000 U/mL were observed in 41% vs. 24% of older adults.
• Stage at diagnosis in younger patients:
  • Resectable: 8.3%
  • Borderline: 20.8%
  • Locally advanced: 33.3%
  • Metastatic: 37.5% (no significant difference vs. older group; p = 0.61).
• Only 4.2% of younger patients had traditional risk factors (smoking, obesity, diabetes).
• Among those without any risk factor, 78% presented with advanced-stage disease.

Conclusion

Pancreatic cancer in adults under 50 is an emerging and underrecognized challenge. In our cohort, younger patients experienced longer diagnostic delays and more frequent advanced-stage presentations—despite lacking classical risk factors. These findings expose a diagnostic blind spot, likely shaped by age-related bias.
Clinicians should not dismiss elevated CA 19-9 values in younger adults, even in the setting of cholestasis, and should maintain a high index of suspicion in those presenting with persistent abdominal symptoms or unexplained weight loss. Earlier imaging and broader clinical vigilance could help reduce missed opportunities for curative intervention in this vulnerable group.

Disclosure

The authors declare no conflict of interest

Introduction

At present, the resection of the pancreatic body and tail generally requires invasive surgical treatment. Laparoscopic resection of the pancreatic body and tail is the predominant methodology to remove lesions in these locations; its safety and surgical planning are relatively mature, but it remains a complex and high-precision surgical operation, requiring abundant experience and skills in laparoscopic surgery, with a 10% rate of complications. Therefore, we use an endoscopic treatment to remove lesions in the pancreatic body or tail directly through animal experiments.

Aims & Methods

Five swine with body weight of 35 ± 2.1 kg were used in this study. First, we used EUS to locate pancreatic body. EUS - guided fine-needle injection was used to label the pancreatic and gastric puncture site using methylene blue. An endoscope with water-jet function and a distal attachment cap was then introduced and a full-thickness incision of approximately 1.5 cm was created on the middle posterior wall of gastric body using Hook/IT knives to get access into the peritoneum. After entering the peritoneum, pancreas was identified following methylene blue. A 2 cm of parenchyma of the pancreatic lobule was then dissected, avoiding the parenchyma around the main pancreatic duct. Electrocoagulation was used to deal with the bleeding of pancreatic duct lobule. Finally, the pancreatic tissue was removed with the assistance of a snare. The endoscope was withdrawn and wound was closed using endoclips.

Results

All the procedures were performed successfully in all the study animals, and there were no perioperative complications. The technical success rate and the survival rate of the pigs were both 100%. After the procedure, routine blood, inflammatory factors, amylase, blood glucose were measured and all the animals recovered well. Endoscopic reexamination and specimen collection of all experimental animals were performed postoperatively based on the study design. In this experiment, a total of 5 pancreatic tissues were removed by endoscopy, in which the resection size of was approximately 2.2 ± 0.8 cm. All the animals survived for 12 weeks until they were euthanized.

Conclusion

The pilot experiment demonstrated that pure flexible endoscopic lobular resection of the pancreas is a feasible and safe approach for removing pancreatic lesions in a porcine model. All animals recovered well without adverse effects, indicating that this minimally invasive technique could serve as an effective alternative to traditional invasive surgical methods for managing lesions in the pancreatic body and tail. This study suggest further exploration and potential application of endoscopic techniques in clinical settings for pancreatic surgeries, potentially leading to improved patient recovery times and reduced surgical risks.

Introduction

Infections in acute pancreatitis are associated with increased morbidity, mortality, and healthcare costs. Early diagnosis is essential to improve prognosis and reduce mortality. The aim of the present study is to evaluate the distribution of infectious complications according to the underlying etiology.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis, consecutively included between March 2017 and June 2019 at a tertiary care hospital. All patients underwent systematic blood testing at admission and at 48 hours. Clinical management adhered to standard clinical practice guidelines. Diagnosis and classification were based on the revised 2012 Atlanta classification. Infectious complications were analyzed in patients with biliary and alcohol-related acute pancreatitis.

Results

Variable	Overall (n = 526)	Biliary (n = 304)	Alcohol-related (n = 39)	p-value
Acute cholangitis (Tokyo-18)
Suspected and/or confirmed	173 (37.6%)	140 (53.8%)	8 (20.4%)	0.001 **
Confirmed cases only	49 (29.2%)	43 (30.7%)	0	0.059
Antibiotic therapy	165 (36.1%)	123 (41.3%)	9 (23.7%)	0.037 **
Extrapancreatic infections (Total)	48 (14.3%)	34 (15.2%)	3 (13%)	1.000
Pneumonia	16 (4.8%)	8 (2.6%)	1 (2.6%)	1.000
Urinary tract infection	28 (8.4%)	25 (8.2%)	1 (2.6%)	0.335
Phlebitis / Catheter-related infection	4 (1.2%)	1 (0.3%)	1 (2.6%)	0.215
Infected pancreatic necrosis	11 (2.4%)	6 (2.1%)	2 (5.3%)	0.230

The distribution of infectious complications occurring during hospitalization is shown in Table 1. Up to 53.8% of patients with biliary acute pancreatitis presented with acute cholangitis according to the Tokyo-18 criteria, whereas this occurred in only 20.4% of alcohol-related cases. All cases of cholangitis in the alcoholic pancreatitis group, as well as the majority of those in the biliary group, met only the criteria for suspected acute cholangitis (100% vs. 53.8%, respectively). Antibiotic therapy was used in 41.3% of biliary pancreatitis cases, with a statistically significant difference compared to alcohol-related pancreatitis (23.7%). No significant differences were observed in the rates of extrapancreatic infections between the two groups, occurring in 15.2% and 13% of biliary and alcohol-related cases, respectively.

Conclusion

Extrapancreatic infections play a key role in the clinical course of acute pancreatitis, particularly in moderate and severe cases. The most frequent sites of infection include the respiratory and urinary tracts, as well as bloodstream infections. These infections are associated with an increased risk of complications, prolonged hospital stays, and higher mortality.
The characteristics of infections vary according to the etiology of pancreatitis. In our cohort, biliary pancreatitis was significantly more often associated with acute cholangitis, which is consistent with the pathophysiology of biliary-origin pancreatitis. Among patients with alcohol-related pancreatitis, up to 20% met criteria for suspected cholangitis; however, none fulfilled the criteria for confirmed cholangitis. This may be explained by the presence of acute-phase reactants and transient cholestasis, potentially leading to the administration of unnecessary antibiotic therapy.
Although previous studies have reported higher rates of respiratory infections in alcohol-related acute pancreatitis, our data showed no significant differences in these infections—or in infectious complications overall—between the two etiologies.

References

1. Petrov, M. S., Shanbhag, S., Chakraborty, M., Phillips, A. R. J., & Windsor, J. A. (2010). Organ Failure and Infection of Pancreatic Necrosis as Determinants of Mortality in Patients With Acute Pancreatitis. Gastroenterology, 139(3), 813–820.
2. Siriwardena, A. K., Jegatheeswaran, S., Mason, J. M., Siriwardena, A. K., Jegatheeswaran, S., Mason, J. M., Baltatzis, M., Sheen, A. J., O’Reilly, D. A., Jamdar, S., Deshpande, R., De Liguori Carino, N., Satyadas, T., Qamruddin, A., Hayden, K., Parker, M. J., Butler, J., & McIntyre, B. (2022). A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. The Lancet Gastroenterology & Hepatology, 7(10), 913–921.
3. Valverde-López, F., Martínez-Cara, J. G., & Redondo-Cerezo, E. (2022). Pancreatitis aguda. Medicina Clínica, 158(11), 556–563.