Preliminary study of single-operator cholangioscopy for diagnosing pancreatic cystic lesions

New and emerging technology in the diagnosis and treatment of pancreatic cysts

Pancreatic cysts have always presented as a diagnostic dilemma due to the difficulties in identifying patients with current imaging modalities that could most benefit from surgical intervention. Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystadenomas (MCNs) carry the highest malignant potential of all pancreatic cysts and pancreatic adenocarcinoma carries a high mortality as the fourth leading cause of cancer-related deaths. However, surgery to remove benign cysts also carries a high morbidity and occasional mortality. Opportunities to identify and reduce pre-cancer lesions must be aggressively pursued. Multidetector helical CT (MDHCT) or an up-to-date MRI is the first diagnostic tool to evaluate a suspected pancreatic lesion. Currently, review by a multidisciplinary group who specialize in pancreatic cysts and pancreatic cancer is advised to review factors such as a patient's comorbidities, the type of surgery needed to remove the cyst and the estimated morbidity and mortality associated with the procedure. Some recent data are emerging to assist with identifying those at highest risk such as cyst fluid analysis, laser endomicroscopy, and artificial intelligence (AI). This article reviews the current status, benefits, challenges and future prospects on diagnosis and treatment of pancreatic cysts. Further prospective randomized control trials are needed to determine the optimal management and treatment for patients with pancreatic cysts.

Diagnostic value of SpyGlass for pancreatic cystic lesions: comparison of EUS-guided fine-needle aspiration and EUS-guided fine-needle aspiration combined with SpyGlass

BACKGROUND AND AIMS

No study has evaluated the diagnostic value of SpyGlass by comparing SpyGlass results and non-SpyGlass results. In this retrospective study, we aimed to compare the diagnostic value of EUS-guided fine-needle aspiration (EUS-FNA) and EUS-FNA combined with SpyGlass to evaluate whether SpyGlass is valuable for increasing the diagnostic yield of EUS-FNA.

METHODS

From April 2015 to April 2020, 251 patients suspected of having pancreatic cystic lesions (PCLs) by imaging techniques who then underwent EUS-FNA were retrospectively enrolled. Only 98 patients who underwent surgical resection with a pathological diagnosis of pancreatic cystic lesion (PCL) were studied. The diagnostic performance outcomes were compared between the EUS-FNA group (EUS-FNA alone, n = 40) and the SpyGlass group (EUS-FNA combined with SpyGlass, n = 58) to assess the value of SpyGlass in diagnosing PCLs.

RESULTS

There were 71 females and 27 males with an overall mean age of 47.6 years. The median diameter of the PCLs was 42.2 mm (range, 11.4-100.0 mm). Approximately 37 cysts were localized in the head/neck of the pancreas, while 61 in the body/tail. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the EUS-FNA group were 96.4% (27/28), 83.3% (10/12), 93.1% (27/29), 90.9% (10/11) and 92.5% (37/40), while those in the SpyGlass group were 100% (54/54), 75% (3/4), 98.2% (54/55), 100% (3/3) and 98.3% (57/58), respectively. The diagnostic accuracy rate in the SpyGlass group was higher than that in the EUS-FNA group; however, no significant difference was found between the two groups (P = 0.368). The diagnostic accuracy of evaluating specific cyst types in the EUS-FNA group was 85% (34/40), similar to that in the SpyGlass group (85.0% vs 84.5%, P = 0.944).

CONCLUSION

SpyGlass seems less valuable for the diagnosis of PCLs when EUS and EUS-FNA have been performed by experienced endoscopists.

Long-term outcomes of EUS-guided lauromacrogol ablation for the treatment of pancreatic cystic neoplasms: 5 years of experience

Background and Objectives

We initially reported EUS-guided lauromacrogol ablation (EUS-LA) to treat pancreatic cystic neoplasms (PCNs); however, its long-term effectiveness remains unknown. This study was performed to further determine the effectiveness of EUS-LA in a larger population with a long-term follow-up based on 5 years of experience with EUS-LA.

Materials and Methods

From April 2015 to April 2020, 279 patients suspected of having PCNs were prospectively enrolled, and seventy patients underwent EUS-guided ablation using lauromacrogol alone. Fifty-five patients underwent follow-up, 35 of whom had a follow-up duration of at least 12 months. The effectiveness of ablation was determined based on volume changes.

Results

Among the fifty female and twenty male patients with an overall mean age of 50.3 years, cysts were located in the head/neck of the pancreas in 37 patients (52.9%) and in the body/tail of the pancreas in 33 patients (47.1%). The adverse events rate was 3.6% (3/84), with 14 patients undergoing a second ablation. Among the 55 patients who underwent follow-up, the median cystic volume sharply decreased from 11,494.0 mm³ to 523.6 mm³ (P < 0.001), and the mean diameter decreased from 32.0 mm to 11.0 mm (P < 0.001). Postoperative imaging showed complete resolution (CR) in 26 patients (47.3%) and partial resolution (PR) in 15 (27.3%) patients. CR was observed in 18 (51.4%), and PR was observed in 9 (25.7%) patients among the 35 patients followed for at least 12 months.

Conclusions

EUS-LA was effective and safe for the treatment of PCNs with stable effectiveness based on at least 12 months of follow-up.

Application of EUS-based techniques in the evaluation of pancreatic cystic neoplasms

Pancreatic cystic neoplasms (PCNs) are being detected increasingly frequently due to the widespread use of high-resolution abdominal imaging modalities. Some subtypes of PCNs have the potential for malignant transformation. Therefore, accurate diagnosis of PCNs is crucial to determine whether surgical resection or surveillance is the best management strategy. However, the current cross-section imaging modalities are not accurate enough to enable definite diagnoses. In the last decade, EUS-based techniques have emerged, aiming to overcome the limitations of standard cross-section imaging modalities. These novel EUS-based techniques were primarily designed to acquire distinct images to make radiological diagnoses, collect cyst fluid to undergo biochemical or molecular analyses, and obtain tissue to conclude the pathological diagnoses. In this article, we present a comprehensive and critical review of these emerging EUS techniques for the diagnosis of PCNs, with emphasis being placed on the advantages, feasibilities, diagnostic performances, and limitations of these novel techniques.

Endoscopic ultrasound-guided injective ablative treatment of pancreatic cystic neoplasms

With the development of cross-sectional imaging modalities and the increasing attention being paid to physical examinations, the prevalence of pancreatic cystic neoplasms (PCNs) has increased. PCNs comprise a broad differential spectrum with some PCNs having low or no malignant potential and others having high malignant potential. The morbidity and mortality rates related to major pancreatic surgical resection are high. Long-term surveillance may not only increase the financial burden and psychological stress for patients but also result in a missed malignancy. Minimally invasive endoscopic ultrasound (EUS)-guided ethanol ablation was first reported in 2005. Several other agents, such as paclitaxel, lauromacrogol, and gemcitabine, were reported to be effective and safe for the treatment of PCNs. These ablative agents are injected through a needle inserted into the cyst via transgastric or transduodenal puncture. This treatment method has been substantially developed in the last 15 years and is regarded as a promising treatment to replace surgical resection for PCNs. While several reviews of EUS-guided ablation have been published, no systematic review has evaluated this method from patient preparation to follow-up in detail. In the present review, we systematically describe EUS-guided injective ablation with regard to the indications, contraindications, preoperative treatment, endoscopic procedure, postoperative care and follow-up, evaluation method, treatment efficiency, safety profile, tips and tricks, and current controversies and perspectives.

Position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel

Background and aim  Recently, several guidelines with divergent recommendations on management of pancreatic cystic neoplasm have been published but the role of endoscopic ultrasound (EUS)-guided pancreatic cyst ablation has not been thoroughly addressed. The aim of the current paper is to explore the issues surrounding EUS-guided pancreatic cyst ablation by generating a list of clinical questions and providing answers based on best scientific evidence available. Methods  An expert panel in EUS-guided pancreatic cyst ablation was recruited from members of the Asian EUS group and an international expert panel. A list of clinical questions was created and each question allocated to one member to generate a statement in response. The statements were then discussed in three Internet conference meetings between October 2016 and October 2017. The statements were changed until consensus was obtained. Afterwards, the complete set of statements was sent to all the panelist to vote on strength of the statements, classification of the statement sand grading of the evidence. Results  Twenty-three statements on EUS-guided drainage of pancreatic cyst ablation were formulated. The statements addressed indications for the procedures, technical aspects, pre-procedure and post-procedure management, management of complications, and competency and training in the procedures. Conclusion  The current set of statements on EUS-guided pancreatic cyst ablation are the first to be published by any endoscopic society. Clinicians interested in developing the technique should reference these statements and future studies should address the key issues raised in the document.

New horizons in the endoscopic ultrasonography-based diagnosis of pancreatic cystic lesions

Pancreatic cystic lesions (PCLs) are increasingly being identified because of the widespread use of high-resolution abdominal imaging. These cysts encompass a spectrum from malignant disease to benign lesions, and therefore, accurate diagnosis is crucial to determine the best management strategy, either surgical resection or surveillance. However, the current standard of diagnosis is not accurate enough due to limitations of imaging and tissue sampling techniques, which entail the risk of unnecessary burdensome surgery for benign lesions or missed opportunities of prophylactic surgery for potentially malignant PCLs. In the last decade, endoscopic innovations based on endoscopic ultrasonography (EUS) imaging have emerged, aiming to overcome the present limitations. These new EUS-based technologies are contrast harmonic EUS, needle-based confocal endomicroscopy, through-the-needle cystoscopy and through-the needle intracystic biopsy. Here, we present a comprehensive and critical review of these emerging endoscopic tools for the diagnosis of PCLs, with a special emphasis on feasibility, safety and diagnostic performance.

Pancreatic Cystic Lesions: New Endoscopic Trends in Diagnosis

The diagnosis of incidental pancreatic cystic lesions is increasing in the general population because of the routine use of cross-sectional imaging modalities. Not all cysts are neoplastic, and the majority of cystic neoplasms have a low overall likelihood of progression to malignancy. Current management is based on imaging and cyst fluid analysis, but we are not able to diagnose the specific type of cyst and its malignant potential in a significant number of patients. Better diagnostic tools are required to avoid unnecessary surgical resections that carry an important risk of morbidity and mortality. Herein we review current evidence concerning the use of new endoscopic modalities for the evaluation of pancreatic cystic lesions. We focus our discussion on the new cyst fluid markers, and the advancements on modalities such as confocal endomicroscopy, contrast-enhanced endoscopic ultrasound, and the use of Spyglass. We also discuss the use of new devices to improve the cellular yield from cyst fluid and to obtain cyst-wall tissue, namely the cytology brush, the fine needle biopsy, and forceps for cyst-wall biopsy.