Introduction

The adoption of minimally invasive techniques in pancreatic surgery remains challenging due to technical complexity and uncertain clinical benefits. This meta-analysis compares perioperative outcomes between minimally invasive (laparoscopic/robotic) and open pancreatic surgery using data from randomized controlled trials (RCTs).

Aims & Methods

A systematic literature search was conducted in MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science databases from inception through January 2025. The search strategy included terms related to "minimally invasive surgery," "pancreatectomy," and "randomized controlled trials." We included RCTs that compared minimally invasive (laparoscopic or robotic) versus open surgical approaches for either distal pancreatectomy (DP) or pancreatoduodenectomy (PD) in adult patients.A random-effects meta-analysis was conducted, assessing adverse events through riskr atios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results

The meta-analysis incorporated data from 10 randomized controlled trials comprising a total of 1,757 patients. Analysis of postoperative pancreatic fistula (POPF) rates revealed no significant difference between minimally invasive and open approaches, with an overall risk ratio of 0.92 (95% CI 0.70-1.21, p=0.57). Subgroup analysis by procedure type showed consistent findings, with a risk ratio of 1.07 (95% CI 0.67-1.71, p=0.14) for distal pancreatectomies and 0.85 (95% CI 0.60-1.20, p=0.16) for pancreatoduodenectomies, both demonstrating comparable outcomes between surgical approaches. Surgical site infection analysis demonstrated a significant advantage for minimally invasive techniques, with an overall 41% reduction in risk (RR 0.59, 95% CI 0.40-0.85, p<0.01). This benefit was particularly evident in pancreatoduodenectomies (RR 0.54, 95% CI 0.35-0.84). Mortality outcomes showed no significant differences between groups, with an overall risk ratio of 0.98 (95% CI 0.49-1.95, p=0.96). Subgroup mortality analysis revealed risk ratios of 0.34 (95% CI 0.06-2.16) for distal pancreatectomies and 1.16 (95% CI 0.52-2.56) for pancreatoduodenectomies, with neither reaching statistical significance. Heterogeneity assessments showed moderate variation in POPF analyses (I²=41%) but minimal heterogeneity in SSI (I²=0%) and mortality (I²=0%) outcomes. Tests for subgroup differences were non-significant for all outcomes (p>0.23), indicating consistent effects across procedure types.

Conclusion

This meta-analysis demonstrates that MIS pancreatic surgery significantly reduces surgical site infections while maintaining comparable rates of pancreatic fistula and mortality to open approaches. These findings support the safety of MIS techniques while highlighting their potential infection-related benefits.

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

EUS-guided drainage using lumen-apposing metal stents (LAMSs) and direct endoscopic necrosectomy (DEN) are primary treatment modalities for symptomatic pseudocysts and walled-off pancreatic necrosis (WOPN). However, bleeding is a frequent and serious adverse event associated with these procedures, often requiring radiological or surgical interventions also due to the limitations of conventional endoscopic hemostatic techniques. PuraStat is a novel topical hemostatic agent that has demonstrated excellent results in managing gastrointestinal bleeding.

Aims & Methods

Our aim was to evaluate the efficacy and safety of PuraStat in managing bleeding secondary to EUS-guided drainage and DEN of pancreatic fluid collections (PFCs). In this multicenter, retrospective, observational study we described 27 patients who underwent PuraStat treatment because of active bleeding during or after EUS-guided drainage or DEN sessions of pseudocysts or WOPN between 2017 and 2024.

Results

38 bleeding episodes were recorded (10 patients with WOPN experienced multiple bleeding events). The bleeding type was oozing in 36 cases and spurting in 2 cases. PuraStat was successfully applied in 100% of patients and achieved successful hemostasis in 96.5% of cases. No re-bleeding occurred. No PuraStat-related adverse events were recorded.

Conclusion

PuraStat is a safe, effective, and easy-to-use hemostatic agent for managing oozing hemorrhages related to PFCs EUS-guided drainage or DEN. Prospective and comparative studies are needed to confirm these preliminary data.

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

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

Chronic pancreatitis (CP) may have differences in causes, presentations and progression related to sex. There are few studies describing the sex related phenotype of CP.

Aims & Methods

We aimed to study sex differences in etiology, complications and treatment of CP in a large, North-European CP cohort. Data were extracted from the Scandinavian Baltic Pancreatic Club (SBPC) database. The collected data included sex, age, etiology, anthropometric measures, data for smoking and alcohol exposures and data on treatment and complications from CP. Differences between sexes were compared with multiple logistic regression models.

Results

We included 1922 patients in the analyses, of whom 1264 were men. Mean age of CP onset was 52.5 (SD 15.0) years in men and 51.5 (SD 16.4) years in women (p=0.2). In univariate analysis alcohol etiology and smoking was associated with male sex, whereas hereditary pancreatitis, efferent duct obstruction, autoimmune pancreatitis were associated to female sex. Numbers of men and women with non-alcoholic etiology were almost equal (461 and 422, respectively). In multivariate analysis including all etiologies, time with disease and age; alcohol etiology remained strongly associated to male sex (OR 2.92 (2.29-3.71), p<0.001), whereas duct obstruction etiology was associated with female sex (OR 0.62 (0.44-0.89), p=0.01).
Significantly more women were underweight (p<0.001), and more men were overweight (p<0.001). Concerning other complications, diabetes mellitus (DM) was strongly associated with men (OR 1.62 (1.27-2.07), p<0.001), whereas osteoporosis was strongly associated with women (OR 0.47 (0.32-0.70), p<0.001). Recurrent acute pancreatitis and exocrine insufficiency were equally distributed between the sexes. There were no differences between sexes for medical, endoscopic or surgical treatment options.

Conclusion

More men than women had alcohol induced CP, but there was almost no difference in absolute numbers of men and women with non-alcoholic CP. Among the CP patients, DM was associated with men, while osteoporosis was associated with women.