Introduction

Infected necrotizing pancreatitis is preferably managed by delaying invasive intervention. The POINTER trial demonstrated that postponing drainage can avoid the need for invasive procedures in one-third of patients, who were successfully treated with antibiotics alone.¹ In this setting, fine needle aspiration (FNA) may facilitate targeted, culture-based antimicrobial therapy.

Aims & Methods

We aimed to assess the value of FNA in guiding antimicrobial treatment in a large cohort of patients with necrotizing pancreatitis. Secondary aims included evaluation of periprocedural complications, agreements between FNA and drainage cultures, and differences in culture results between endoscopic and percutaneous FNA.
A post-hoc analysis was performed on 618 patients with acute necrotizing pancreatitis (CTSI ≥3) from 17 hospitals (2010–2020).

Results

In total, 68 of 618 patients (11%) with acute necrotizing pancreatitis underwent an FNA procedure and in total 71 FNA procedures were performed. Eleven (15%) were an endoscopic ultrasound-guided FNA (EUS-FNA) and 60 (85%) were percutaneous FNA. No periprocedural complications such as bleeding and perforation were observed.
In 4/22 patients (18%) who received antimicrobial treatment before a percutaneous FNA procedure, non-susceptible pathogens were cultured. In 7/43 (16%) of the positive percutaneous FNA cultures, the microorganisms were resistant to three commonly administered empiric antibiotic regimes with little difference between carbapenem and non-carbapenem regimes. All were due to Enterococcus species.
Subsequent (peri-)pancreatic drainage procedures of infected necrosis was performed in 51/68 (75%) patients. Median time between FNA and subsequent drainage was 10 days (IQR 4-21). Species identification of drainage culture performed within 14 days after FNA (n=29) and FNA culture averaged 40% (IQR100, p=0.08).
Nine of 11 (82%) EUS-FNA cultures were positive and all were polymicrobial, as compared to 12/44 (29%) of the positive percutaneous FNA (p<0.001).

Conclusion

Percutaneous FNA is a safe procedure with potential to guide antimicrobial therapy in patients with (high suspicion) of infected necrotizing pancreatitis. Initial antimicrobial therapy upon percutaneous FNA did not cover in 18% of patients based on FNA culture results, mostly due to pathogens that are non-susceptible to empirical regimes, especially Enterococcus species. All positive EUS-FNA samples were polymicrobial and appear to carry a high risk of periprocedural contamination, therefore percutaneous FNA is preferred in this setting with the goal of guiding antimicrobial treatment. Common empirical antibiotic regimes often require adjustment to adequately target all microorganisms identified in the FNA specimen culture. Implementation of routine microbiological diagnostics of percutaneous FNA specimens in the care for necrotizing pancreatitis patients may prevent treatment failure and prolonged treatment duration. Although large prospective studies are needed, it is clear that the role of FNA needs reconsideration.

References

1) Boxhoorn L, van Dijk SM, van Grinsven J, et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-1381. doi:10.1056/nejmoa2100826

Disclosure

No conflict of interest

Introduction

Aims & Methods

The purpose of this study is to evaluate the feasibility of extracting RNA in sufficient quantity and quality to perform genomic analyses from specimens obtained through EUS-fine needle aspiration (EUS-FNA) of PanNENs, comparing three methods of RNA preservation and extraction.

Results

Conclusion

Introduction

Pancreatic neuroendocrine tumors (NETs) are rare neoplasms that are classified as functional (F-NET) or nonfunctional (NF-NET) depending on the presence or absence of excess hormone production. Endoscopic Ultrasound guided fine needle aspiration (EU-FNA) is often used to diagnose NETs but there are limited data on its sensitivity for this purpose.

Aims & Methods

To determine the sensitivity of EUS-FNA for the diagnosis of a NET.
A prospective randomized trial study, from May 2013 to Abril 2025 was performed in a referred Gastrointestinal hospital in Brazil. A total of 184 patients underwent EUS for suspected NETS and collected materials from fine needle aspiration and sent to histopathology analyzes. The diagnosis of a NET was confirmed by: 1) EUS-FNA with or without confirmatory immune chemistry (ICC) with synaptophysin and chromogranin form pancreatic mass or metastatic site; or 2) an alternative biopsy method and/or surgical resection of the pancreas or other metastatic site

Results

184 patients (112 male; median age: 54 yrs, range: 21-78 yrs) with 68 (37%) F-NETs and 116 (63%) NF-NETs were identified. By EUS, the tumors were located in the pancreas head, body, tail or were multifocal in 76 (41%), 54 (29%), 38 (21%) and 16 (18%), respectively. Of these 184, 152 (83%) underwent EUS-FNA of a pancreatic mass, 72 (47%) of whom also had a EUS-FNA of an alternative (nonpancreatic) site including liver (n=30; 16%), another lesion in the pancreas (n=14; 8%), or lymph node (n=18; 10% peripancreatic in 10, celiac in 6 and mediastinal in 2). Immunohistochemistry was performed in 102/152 (67%) EUS-FNA specimens and the result were: ICC-positive (n=88), ICC-negative (n=10), not interpretable (n=2) or inadequate for interpretation (n=2), Surgery was performed in 82 (54%): distal pancreatectomy (n=32), Whipple procedure (n=20), enucleation (n=20) and subtotal (n=4) and total pancreatectomy (n=2). The remaining four who underwent surgery had an exploration laparotomy only. 132 patients had a confirmed diagnosis of NET and the sensitivity of EUS-FNA was respectively: all patients 84%, F-NET 78%, NF-NET (89%) and lesions less than or equal to 13 mm (62%). The results of the false-negative EUS-FNA biopsies of pancreas (n=24) were interpreted as: normal in 4; suspicious in 4, nondiagnostic in 10, adenocarcinoma in 4, and a solid pseudopapillary tumor in 2.

Conclusion

EUS-FNA is a sensitive method for the diagnosis of pancreatic NETS but yield is lower in tumor smaller than 13mm in diameter.

Introduction

Malnutrition is an early yet frequently overlooked dimension of pancreatic cancer, often present at diagnosis due to systemic inflammation, cachexia, or silent pancreatic exocrine insufficiency (PEI). Low body mass index (BMI) and hypoalbuminemia are individually recognized as risk factors for poor outcomes, but their combined evaluation may offer a more robust tool for risk stratification. The Nutritional Risk Index (NRI), which integrates both parameters, is a simple, validated score that remains underused in pancreatic oncology.

Aims & Methods

This study aimed to evaluate whether undernutrition at diagnosis, assessed by BMI, albumin, and NRI, predicts non-resectability and early mortality in patients with pancreatic cancer.
We retrospectively analyzed all pancreatic cancer cases diagnosed at a tertiary center between January 2020 and December 2024. BMI was categorized as <20 vs. ≥20 kg/m². Serum albumin levels were collected, and NRI was calculated using the simplified formula: 1.519 × albumin (g/L), due to unavailable weight loss data. Patients were stratified according to NRI into no risk (≥97.5), moderate risk (83.5–97.4), and severe risk (<83.5). Tumor stage and resectability were assessed through imaging (resectable) or histology (non-resectable). A subgroup analysis was performed on patients with available 3-month survival data. Statistical comparisons used chi-square and non-parametric tests.

Results

Among 293 patients (mean age 64±11 years; 55% male), BMI data were available for 248 cases. Of these, 101 (38.4%) had a BMI <20 kg/m². This group showed lower rates of curative surgery (8.8% vs. 16.9%; p=0.04), more frequent metastatic disease (52.7% vs. 34.2%; p=0.01), and higher rates of hypoalbuminemia (44% vs. 21%; p<0.01).
Serum albumin was available for 289 patients. According to NRI, 39% had severe nutritional risk (NRI <83.5) and 42% had moderate risk. Severe NRI was strongly associated with metastatic disease (61% vs. 28%; p=0.002) and early mortality.
Among 112 patients with 3-month survival data, 83 (74%) had died. Mortality was significantly higher in patients with BMI <20 (82.6% vs. 66.1%; p=0.03) and was even more pronounced in those with NRI <83.5 (87.1% vs. 58.2%; p<0.01).

Conclusion

Undernutrition at diagnosis—whether assessed by BMI, albumin, or NRI—is a strong and early indicator of poor prognosis in pancreatic cancer. The NRI, by combining two simple and routinely available markers, could serve as a practical triage tool to support early nutritional interventions and treatment decisions. Its integration into initial staging workflows may improve outcomes, especially if pancreatic exocrine insufficiency is also considered. Further multivariate analyses are needed to validate NRI as an independent predictor and to facilitate its routine use in multidisciplinary care planning.

Introduction

The consequences of chronic pancreatitis (CP) may not be exclusively limited to the pancreas or restricted to the gastrointestinal tract but could also be systemic. To date, the relationship between chronic pancreatitis and cardiovascular risk factors has not been studied extensively. We conducted a systematic review and meta-analysis to examine if the combination of chronic inflammatory changes may possibly place CP patients at risk for cardiovascular disease.

Aims & Methods

We systematically searched PubMed, Scopus, and Cochrane Register of Controlled Trials for observational studies that compared major cardiovascular outcomes in patients with chronic pancreatitis. The outcomes explored were: (1) acute coronary disease/myocardial infarction; (2) hypertension; (3) hyperlipidemia; and (4) diabetes mellitus. We computed odds ratio (OR) for binary endpoints, with 95% confidence intervals (CI). Heterogeneity was examined I² statistics; p values less than 0.10 and I² > 25% were considered significant for heterogeneity.

Results

Four observational studies comprising a total of 57,721 patients with chronic pancreatitis were included in this meta-analysis. The most consistent finding across studies was a significantly higher risk of diabetes mellitus in patients with chronic pancreatitis compared to a control group without chronic pancreatitis (OR 4.77; 95% CI 1.32–17.28; p=0.017; I²=100%). In contrast, no statistically significant associations were found between chronic pancreatitis and other cardiovascular outcomes, including cerebrovascular disease (OR 1.59; 95% CI 0.98–2.57; p=0.05; I²=99.4%), acute coronary syndrome/myocardial infarction (OR 1.35; 95% CI 1.00–1.82; p=0.049; I²=95.4%), hypertension (OR 0.52; 95% CI 0.30–7.61; p=0.608; I²=99.9%) or hyperlipidemia (OR 2.60; 95% CI 0.36–18.77; p=0.342; I²=100%).

Conclusion

The results of our meta-analysis suggest that chronic pancreatitis is not associated with increased risk of cardiovascular disease despite being associated with a higher risk of diabetes mellitus.

Introduction

The aim of this study is to evaluate the volume of biliopancreatic diseases at AUSL Romagna and assess their burden on healthcare system from emergency care to subsequent hospitalization in dedicated departments.

Aims & Methods

We designed a longitudinal, retrospective, descriptive study, considering patients who accessed the Emergency Departments (ED) in all first and second-level centers of AUSL Romagna from January 2018 to December 2024, having blood lipase levels above the upper limit (≥60 U/L). We divided these patients into two groups: the first one (identified as “acute pancreatitis” (AP)) with lipase levels above three times upper limit (≥180 U/L), and the second group (identified as “other biliopancreatic (BP) diseases”) including patients with high lipase level associated to other gastrointestinal conditions, evaluating their care pathways.

Results

The total number of emergency admissions to AUSL Romagna with lipase levels ≥ 60 U/L was 29011, accounting for 1% of annual emergency admissions, with the majority triaged as green (minor urgency). Of these, 9204 patients (32%) were discharged with a diagnosis compatible with AP (13%, N= 3669) or other BP diseases (19%, N= 5535), with consistent rates over the years. Male sex was predominant for BP group with a median age of 63 years, female sex for the AP group and median age of 66 years. Nearly all patients with AP (94%) required subsequent hospitalization, primarily in the gastroenterology department (32%), followed by general medicine (25%) and general surgery (15%). In the other BP diseases group, fewer than half (40%) required subsequent hospitalization. The discharge diagnoses from specialized departments showed an increase in diagnostic accuracy compared to initial assessments, reflecting initial missed diagnoses, appropriate re-evaluations during hospitalization, complications, etc. From an economic perspective, hospital stays in specialized departments lasted an average of 9.5 days, with an average cost of €3,784 per stay. Specifically, hospitalizations in the gastroenterology department for AP had an average duration of 9.3 days, with a total cost of €4129740 for 1181 admissions. For other BP diseases, the costs for a total of 522 hospitalizations amounted to €1808899, with an average stay of 9.3 days. Most hospitalizations ended in discharge to home (84%), with an in-hospital mortality rate of 4%.

Conclusion

Our study provided a detailed roadmap of patients with biliopancreatic diseases in AUSL Romagna (an area covering 1.2 millions of inhabitants), from their admission in ED to their discharge by different departments. BP diseases account for 1% of all ED accesses and most of the cases are characterized by medium-high complexity, with an economic annual burden of €2.8 million. These results may support the healthcare policy towards an optimization of economic and human resources to improve patient’s management and outcomes.

Introduction

Biliary stones are a leading cause of acute pancreatitis (AP). Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard of care when concomitant cholangitis or confirmed choledocholithiasis is present¹. However, spontaneous migration of biliary stones in the latter occurs in approximately 20% of cases², potentially exposing patients to the inherent risks of ERCP without a definitive therapeutic benefit.

Aims & Methods

This study aimed to identify predictors of spontaneous common bile duct stone clearance in patients with acute biliary pancreatitis. We conducted a retrospective cohort study of consecutive patients diagnosed with acute pancreatitis and confirmed choledocholithiasis, who subsequently underwent ERCP. Patients with a prior ERCP or concurrent acute cholangitis were excluded.

Results

Forty-four patients were included, 61.4% female with a mean age of 67±18 years. In 31.8% of cases, no stone was identified at ERCP, suggestive of spontaneous resolution. The median interval from admission to ERCP was 10 days and did not significantly differ between patients with and without stones (p=0.872). Serum levels of total bilirubin (2.5±2.0 vs. 2.3±2.9 mg/dL, p=0.825), AST (160±31 vs. 171±50 U/L, p=0.505), and alkaline phosphatase (267±135 vs. 210±70 U/L, p=0.187) were not significantly different between groups with and without stones at ERCP, respectively. Neither cholecystectomy status (p=0.722), common bile duct dilation on imaging (p=0.955), nor number of stones (p=0.829) correlated with spontaneous clearance. Interestingly, patients without lithiasis at ERCP had significantly smaller common bile duct stones on imaging compared to those with retained stones (5 ± 3 mm vs. 8 ± 5 mm, p=0.025). Stone size was an independent predictor of spontaneous resolution in the multivariate analysis (OR = 1.24; 95% CI: 1.01–1.52; p = 0.036), with a diameter ≥7 mm yielding a sensitivity of 63% and a specificity of 78.6% for predicting the presence of stones at ERCP.

Conclusion

Spontaneous passage of biliary stones is common in the context of acute biliary pancreatitis, particularly when their size is ≤7 mm. These findings support a risk-adapted strategy, in which Endoscopic Ultrasound may be employed to confirm choledocholithiasis immediately prior to ERCP in patients with small biliary stones.

References

1. Manes, G. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 51, 472–491 (2019).
2. Sperna Weiland, C. J. et al. Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP. Surg. Endosc. 37, 1194–1202 (2023).