Introduction

Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM) (1, 2, 3). Knowledge about the effects of endoscopic treatment of pancreatic necrosis on pancreatic endocrine function is limited.

Aims & Methods

The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen apposing metal stents (LAMS) using a Hot AxiosTM Stent Device and to evaluate the risk factors associated with the occurrence of NOD.
Methods: We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for 12 months or more after stent removal. The occurrence of NOD was assessed only in patients without prior DM and it was compared to a controlled group of patients matched for age and gender. Diabetes was defined according to the American Diabetes Association (ADA) criteria.

Results

Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; mean age, 59.92 ±11.3), 13 patients (26%) had pre-existing DM while ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in healthy controls (2%, p = 0.002). NOD patients were older than non-DM patients (63.5 vs. 56 years old, p=0.042) and their WON was located more frequently in the body and tail, or in the entire pancreas (p<0.001). In addition, the mean mCTSI was higher in NOD patients (p=0.019) than in non-DM patients, while direct endoscopic necrosectomy (DEN) was also performed in more patients (90% vs 59.3%), with a higher median number of DEN sessions (4 vs. 1, p<0.001). According to multivariate analysis, the number of DEN sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients were more likely to be non-obese (90% vs. 30%, p=0.017) compared to patients with pre-existing DM. They also had poor glycemic control (70% vs. 23.1%, p=0.040) and required more DEN sessions (4 vs. 1, p=0.017) to achieve WON resolution.

Conclusion

In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up, which was higher than the 2% recorded in healthy controls. Patients with WON located in the body and tail or whole pancreas were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence.

References

1.Tu, J., Yang, Y., Zhang, J., Yang, Q., Lu, G., Li, B., et al. (2018). Effect of the disease severity on the risk of developing new-onset diabetes after acute pancreatitis. Medicine 97:e10713
2. Umapathy, C., Raina, A., Saligram, S., Tang, G., Papachristou, G. I., Rabinovitz, M., et al. (2016). Natural history after acute necrotizing pancreatitis: a large US Tertiary care experience. J. Gastrointest. Surg. 20, 1844–1853.
3. Winter Gasparoto, R. C. G., De Jorge Racy, M. C., and Campos, T. D. (2015). Long-term outcomes after acute necrotizing pancreatitis: what happens to the pancreas and to the patient? first episode. J. Pancreas 16, 159–166.

Clinical Case Summary

Endoscopic ultrasound (EUS)-guided drainage is a first-line treatment for pancreatic pseudocysts (PPC), though 13% of cases have adverse events. A 48-year-old male with a history of acute necrotizing pancreatitis two years prior presented with recurring abdominal pain and weight loss. A CT scan revealed a pseudocyst measuring 120mm, involving the distal body and tail of the pancreas. An EUS-guided transgastric drainage was performed. The pseudocyst was punctured using a 10 Fr cystotome, two 0.035 - inch guidewires were advanced into the cavity. The tract was dilated and two double-pigtail 7Fr/7cm plastic stents were inserted, facilitating the evacuation of fluid. During the procedure an insignificant intracystic haemorrhage was observed. The vital parameters and hemoglobin levels remained stable during and after the procedure.
On the fourth post-procedure day due to subfebrile temperature and no significant regression in the size of the cyst, a balloon dilator was introduced in the tract, dilating it up to 8mm and a 10Fr/3cm double-pigtail stent was put alongside the previous two. Considering the absence of clinical improvement on the fifth post-procedure day, all stents were removed. Balloon dilation until 15mm for two minutes was performed. Using a gastroscope the cyst cavity was inspected, aspirating a significant amount of sanguinopurulent fluid. A coagulum fixated and blocking the entry of the tract was detected and aspirated. The cavity was lavaged and two new 10Fr/5cm plastic double-pigtail stents were placed. Following the procedure the patient achieved clinical improvement and was discharged shortly after. A follow-up CT confirmed a complete resolution of the pseudocyst. The large balloon dilation of the tract with inspection and aspiration of the cavity proved effective in managing insufficient EUS-guided drainage. The procedure has a high success rate, low complication, and recurrence rates and can considerably reduce the length of hospital stay and cost.

References

1. CT image of the giant pseudocyst
2. Ultrasound image of the cyst during the first procedure
3. CT image after the first procedure
4. Endoscopic image of the tract dilation
5. Endoscopic image of the aspiration and revision of the cavity
6. Follow-up CT image with full resolution of the cyst

Introduction

Pancreatic walled-off necrosis (WON) presents a significant challenge in acute pancreatitis management, often necessitating endoscopic intervention for drainage and necrosectomy. However, the optimal selection of stent type for endoscopic drainage remains debatable. This study aimed to evaluate the utility of the QNI classification in guiding stent selection for WON drainage.

Aims & Methods

We conducted a retrospective analysis of patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at a tertiary referral center between January 2022 and September 2023. Patients were divided into two groups based on the QNI classification: Group 1 consisted of patients who had WON affecting 1 quadrant or 2 quadrants with a necrosis of less than 30%. Group 2 consisted of patients whose WON had affected 3 quadrants, 2 quadrants with 30% necrosis, or 1 quadrant with more than 60% necrosis at the time of the index procedure. A WON-based decision was made by the endoscopist regarding the use of LAMS or plastic stents. Necrosectomy was performed in cases of infection following WON drainage. Resolution was considered in clinically asymptomatic patients with WON < 30 mm at the 3-month imaging follow-up.

Results

Forty-eight patients were included in the study, with a mean age of 55.7 (±12.28) and a male-to-female ratio of 2.4:1, 20 patients in Group 1 and 28 patients in Group 2. Except for infection, which occurred more frequently in Group 2, the indications for drainage (pain, weight loss) were similar between the two groups (28% vs 5%, p=0.03). LAMS were used more frequently in group 2 than in group 1 (64% vs 40%, p=0.001). The mean number of endoscopic procedures in Group 1 was 1.7 and in Group 2 it was 3. The interval between endoscopic procedures in Group 1 and Group 2 was 20.3 days and 12.4 days, respectively (p=0.05). Clinical resolution at 3 months showed no significant difference between groups, with rates of 90% vs 85% (p=0.87), and the complication rates was 10% vs 14.2% (p=NS). Percutaneous drainage was done in 0% vs 7.14% cases, and surgery was required in 0% vs 7.1% of cases.

Conclusion

As a result of the newly proposed QNI classification system, patients can be guided in the selection of LAMS placement as well as for multidisciplinary management. Severe QNI scores may need more aggressive interventions, yet outcomes are comparable to those with milder disease.

References

Baroud, S., Chandrasekhara, V., Storm, A. C., Law, R. J., Vargas, E. J., Levy, M. J., Mahmoud, T., Bazerbachi, F., Bofill-Garcia, A., Ghazi, R., Maselli, D. B., Martin, J. A., Vege, S. S., Takahashi, N., Petersen, B. T., Topazian, M. D., & Abu Dayyeh, B. K. (2023). Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework. Gastrointestinal endoscopy, 97(2), 300–308.

Introduction

Endoscopic ultrasound (EUS) elastography has emerged as a valuable tool for assessing pancreatic tissue stiffness, aiding in the differentiation of normal pancreas, chronic pancreatitis (CP), and solid pancreatic masses, including pancreatic adenocarcinoma (PDAC) and cholangiocarcinoma (CC). The newly developed two-dimensional shear wave elastography (2D-SWE) provides real-time, quantitative elasticity maps with improved reproducibility. This study aims to evaluate the performance of 2D-SWE during EUS for differentiating normal pancreas, CP, and solid pancreatic tumors.

Aims & Methods

This prospective study included patients undergoing EUS for pancreatic evaluation. All 2D-SWE measurements were made using the Aplio i800 EUS ultrasound machine. Four groups were analyzed: (1) individuals with a normal pancreas, (2) patients with CP (based on Rosemont criteria), (3) patients with PDAC, and (4) patients with CC (all diagnoses confirmed histopathologically). 2D-SWE was performed during EUS using a linear-array echoendoscope. Quantitative elasticity values (kPa) were recorded for the normal pancreas, CP-affected tissue, and tumor lesions. The diagnostic performance of 2D-SWE was assessed using intraclass correlation coefficient (ICC), receiver operating characteristic (ROC) analysis, and pairwise statistical comparisons.

Results

A total of 30 patients were included (6 normal, 5 CP, 17 PDAC, 2 CC). The intra-observer reproducibility of SWE measurements was excellent (ICC = 0.89). Mean elasticity values significantly differed among groups, with PDAC showing the highest variability (mean SWE = 54.1 ± 45.7 kPa, median = 33.1), CC presenting elevated stiffness (mean SWE = 77.4 ± 11.0 kPa), CP showing heterogeneous values (mean SWE = 57.5 ± 52.3 kPa, median = 43.6), and normal pancreas showing the lowest stiffness (mean SWE = 7.5 ± 3.9 kPa, median = 6.2).
ROC analysis for distinguishing malignant solid tumors (PDAC + CC) from normal pancreas showed excellent diagnostic performance (AUC = 0.93). The optimal cutoff of 17.0 kPa yielded a sensitivity of 84.2%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 66.7%, and overall accuracy of 88%.
Pairwise t-tests confirmed a statistically significant difference between PDAC and normal pancreas (p = 0.0007), with trends observed for CC vs normal (p = 0.0605) and CP vs normal (p = 0.099). No statistically significant differences were observed among solid tumor subtypes (PDAC vs CC, PDAC vs CP, CC vs CP).

Conclusion

2D-SWE during EUS provides highly reproducible and quantitative elasticity values that reliably differentiate normal pancreas from solid pancreatic tumors. This method demonstrates excellent diagnostic performance, particularly in identifying PDAC, and shows promising trends for distinguishing CP and CC, supporting its clinical integration in EUS evaluation protocols.

Introduction

The use of contrast-enhanced endoscopic ultrasound (CE-EUS) for characterizing solid pancreatic masses has improved diagnostic capabilities. We aimed to evaluate the performance of an artificial intelligence (AI)-powered system for differential diagnosis of pancreatic adenocarcinoma using CE-EUS.

Aims & Methods

The methodology integrates advanced imaging analysis and machine learning (ML) to develop an automated framework for pancreatic tumor characterization using EUS. A convolutional neural network (CNN) is first trained on labeled non-contrast EUS images to detect and segment the pancreas and tumor regions accurately. Once trained, the CNN is applied to new cases, identifying regions of interest (ROIs) in the non-contrast images, which are subsequently mapped onto the corresponding contrast-enhanced images for further analysis. Time-Intensity Curve (TIC) analysis was performed on the mapped ROIs, extracting a comprehensive set of quantitative parameters describing contrast enhancement dynamics. These parameters include temporal metrics (e.g., time to peak, rise time), intensity measures (e.g., peak intensity, wash-in intensity), slopes (e.g., wash-in and wash-out rates), area-based metrics (e.g., area under the curve), and perfusion-related characteristics (e.g., perfusion index, blood flow). The extracted TIC parameters are then used to train a feedforward neural network (FNN), which learns to differentiate diagnostic categories based on the perfusion characteristics of the lesions. In the final integrated model, the CNN detects pancreas and tumor regions, maps them to contrast-enhanced images, computes TIC parameters, and feeds these into the FNN to provide automated diagnostic predictions.

Results

Retrospective analysis was performed on a prospectively collected dataset of 120 CE-EUS videos obtained from patients with solid pancreatic masses in 3 tertiary referral centers. The dataset included 88 pancreatic adenocarcinomas, 1 lymphoma, 4 metastatic lesions, 10 neuroendocrine neoplasms (G1/G2), 15 cases of chronic pancreatitis, and 2 solid pseudopapillary neoplasms (SPNs). Diagnostic performance was evaluated by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy. Based on CNN analysis, both precision and recall were also calculated. The AI-powered CE-EUS system achieved high diagnostic performance, with an accuracy of over 95% for the diagnosis of pancreatic adenocarcinoma. Precision and recall were also excellent for differentiating adenocarcinoma from other pancreatic lesions based on CNN analysis.

Conclusion

This novel AI-based approach using CE-EUS reliably distinguished pancreatic adenocarcinoma from other solid pancreatic masses. Real-time analysis of time-intensity curve parameters enhances diagnostic accuracy and offers a promising adjunct to traditional EUS methods. Further prospective validation is warranted to confirm these findings and explore clinical applicability.

References

1. Săftoiu A, Vilmann P, Bhutani MS, Hassan H, Hawes R, Dietrich CF, et al. Enhanced endoscopic ultrasound imaging for pancreatic lesions: A review.
World J Gastrointest Endosc. 2022 Jul 16;14(7):369–84. doi:10.4253/wjge.v14.i7.369 PMID: 35967758; PMCID: PMC9367228.
2. Liang T, Zhang H, Wang Y, Sun Y, Ma K, Liu W, et al. Artificial intelligence-assisted endoscopic ultrasound for detection of pancreatic lesions: A systematic review and meta-analysis. World J Gastroenterol. 2023 Feb 21;29(7):1150–1164. doi:10.3748/wjg.v29.i7.1150 PMID: 36849883; PMCID: PMC10720860.

Introduction

Pancreatic pseudocyst (PPC) is a well defined local complication of pancreatitis. It has been reported in 8-41% of patients with history of pancreatitis in children¹. In past, surgical technique was treatment of choice for PPC drainage², however with advancements in endoscopic interventions, endoscopic ultrasound (EUS) guided PPC drainage is preferred in present era. Limited literature is available for EUS guided PPC drainage in pediatrics, owing to structure of echo-endoscope due to its rigid tip³, need of anesthesia and endoscopic skills. This study is one of the largest retrospective data⁴ in which we have shared experience of last 10 years for EUS guided PPC drainage from a tertiary care center of Pakistan.

Aims & Methods

This study aimed to evaluate the safety of EUS-guided PPC drainage in a large paediatric cohort (≤18 years) in Karachi, Pakistan, and assess technical and clinical success.
We retrospectively reviewed the charts of patients ≤18 years who underwent EUS-guided PPC drainage from 2015 to 2024 at the Sindh Institute of Advanced Gastroenterology, a tertiary care centre in Karachi, Pakistan. Data collected include patient demographics, aetiology of pancreatitis, PPC characteristics, procedural details, and outcomes. Technical success was defined as successful stent placement across the cyst gastrostomy. Clinical success included PPC resolution and symptom improvement.

Results

28 patients were referred for EUS-guided PPC drainage, 7 patients had no symptoms when presented, so 21 patients underwent EUS-guided PPC drainage. All patients were given general anesthesia by a pediatric anesthetist, and the airway was secured by endotracheal intubation to avoid the risk of aspiration. out of 21 patients,11 were male, with ages ranging from 6 to 18 years (Mean age 14.00± 3.25 years). 11 patients underwent EUS-guided complete aspiration of pseudocyst, with average pseudocyst size of 4.27 X3.93 cm, ranged from 2X1.2cm to 6.7 x5.6 cm. 10 patients underwent EUS-guided pseudocyst drainage via stent placement. The average size of PPC in this group was 8.39 X 8.02 cm, ranged from 6 X5 cm to 14X10cm. 8 pseudocysts were located along the pancreatic body region, 8 were located along the head and neck, and 5 were located near the tail region. Two Double pig tail plastic stents (DPPS) of 7fr 4cm were placed in 9 patients and 7fr 6cm in one patient transmurally into the cyst-gastrostomy tract, whereas LAMS hot axios 10x20 mm was placed in one patient only. One of the patients had a recurrence of pseudocyst with symptoms after 3 months, hence needing repeat pseudocyst drainage. One patient had displacement of DPPS. None of the patients developed major complications.

Conclusion

Endoscopy guided pancreatic pseudocyst drainage is safe and effective in pediatric population, however this procedure should be done by trained and experienced endoscopists under general anesthesia by pediatric anesthetist and EUS guided technique should be preferred over conventional technique of PPC drainage.

References

1.Park, A., Latif, S.U., Shah, A.U., Tian, J., Werlin, S., Hsiao, A., Pashankar, D., Bhandari, V., Nagar, A. and Husain, S.Z. (2009), Changing Referral Trends of Acute Pancreatitis in Children: A 12-year Single-center Analysis. Journal of Pediatric Gastroenterology and Nutrition, 49: 316-322. https://doi.org/10.1097/MPG.0b013e31818d7db3
2.Szakó L, Mátrai P, Hegyi P, Pécsi D, Gyöngyi Z, Csupor D, Bajor J, Erőss B, Mikó A, Szakács Z, Dobszai D. Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis. Pancreatology. 2020 Jan 1;20(1):132-41
3.Thomson M, Tringali A, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J. Paediatric gastrointestinal endoscopy: European society for paediatric gastroenterology hepatology and nutrition and European society of gastrointestinal endoscopy guidelines. Journal of pediatric gastroenterology and nutrition. 2017 Jan 1;64(1):133-53
4.Nabi Z, Talukdar R, Lakhtakia S, Reddy DN. Outcomes of Endoscopic Drainage in Children with Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis. Pediatr Gastroenterol Hepatol Nutr. 2022 May;25(3):251-262. doi: 10.5223/pghn.2022.25.3.251. Epub 2022 May 9. PMID: 35611379; PMCID: PMC9110851.