Use of antibiotic prophylaxis is not needed for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts: a meta-analysis

Endoscopic Imaging of Pancreatic Cysts

Pancreatic cystic lesions (PCLs) have been diagnosed with increasing frequency likely due to the widespread use of cross-sectional imaging. A precise diagnosis of the PCL is important because it helps identify patients in need of surgical resection and those who can undergo surveillance imaging. A combination of clinical and imaging findings as well as cyst fluid markers can help classify PCLs and guide management. This review focuses on endoscopic imaging of PCLs including endoscopic and endosonographic features and fine needle aspiration. We then review the role of adjunct techniques, such as microforceps, contrast-enhanced endoscopic ultrasound, pancreatoscopy, and confocal laser endomicroscopy.

Predictors of adverse events after endoscopic ultrasound-guided through-the-needle biopsy of pancreatic cysts: a recursive partitioning analysis

BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB.

Antibioprophylaxis in endoscopic ultrasound guided fine needle aspiration in pancreatic cysts: A systematic review and meta-analysis

Antibioprohylaxis (ABP) for pancreatic cystic lesion is still a debated clinical indication. Although professional societies guidelines still recommend ABP in endoscopic ultrasound-fine needle aspiration (EUS-FNA) for pancreatic cystic lesions (PCL), this standard of care recommendation was based on old and weakly planned studies with a small number of patients. Herein, in this work, we provide a critical review with pooled data analysis of the available literature. Overall, the studies reported are weak and limited with small number of patients, the absence of exact definition of infection and the heterogenicity of the type and the duration of the ABP used. Pooled data analysis showed that the effect of ABP on the rate of cyst infection was not significant (OR 0.56, 95% CI 0.17-1.2), with no significant heterogenicity between the results of the studies reviewed and reported (as assessed by Breslow Day test for homogeneity of OR's [P = 0.15]). The pooled infection rate without ABP was 0.89% and 0.36% in the ABP group. Moreover, according to the pooled data infection rate, sample size calculation demonstrated that 6954 patients are needed to show superiority of ABP, with a number needed to treat of 179 patients to prevent single infection. However, through the literature only six studies (1660 patients) reported the cyst infection rate among ABP versus control, making these results scarce and biased by a small number of patients. Therefore, we suggest the need to revise the guidelines, until performing well organized large international study to solve this controversy.

The Value of Serum Tumor Markers and Blood Inflammation Markers in Differentiating Pancreatic Serous Cystic Neoplasms and Pancreatic Mucinous Cystic Neoplasms

Although many studies have emphasized the prognostic and diagnostic value of tumor markers and various inflammation-related markers, their clinical significance in differentiating benign and malignant pancreatic cystic neoplasms (PCNs) remains to be clarified. The present study explored the value of serum tumor markers and inflammation-related biomarkers in the differentiation of pancreatic serous cystic neoplasms (SCNs) and pancreatic mucinous cystic neoplasms (MCNs). A total of 79 patients with PCNs were included in this study, including 35 patients with SCNs and 44 patients with MCNs. Comparison of baseline data with preoperative results of serum tumor markers and associated inflammatory markers revealed significant differences in carbohydrate antigen 199 (CA199) and “lymphocyte × ALB” (LA) between the two groups (p = 0.0023, p = 0.0149, respectively). Univariate and multivariate regression analyses showed that an increase in CA199 and a decrease in LA were relevant risk factors for MCNs. Finally, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated to evaluate the prediction efficiency of each indicator. The results showed that CA199 and LA had good differential diagnostic efficacy for SCNs and MCNs. This is the first to report to demonstrate that LA can be used for the differential diagnosis of SNCs and MCNs.

Impact of Antibiotic Prophylaxis on Infection Rate after Endoscopic Ultrasound Through-the-Needle Biopsy of Pancreatic Cysts: A Propensity Score-Matched Study

Background: Despite weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) of pancreatic cystic lesions (PCLs) is routinely used in clinical practice. We aim to compare a group of patients treated with antibiotics before EUS-TTNB of PCLs and a group who did not undergo antimicrobial prophylaxis. Methods: Out of 236 patients with pancreatic cystic lesions referred to two high-volume centers between 2016 and 2021, after propensity score matching, two groups were compared: 98 subjects who underwent EUS-TTNB under antibiotic prophylaxis and 49 subjects without prophylaxis. Results: There was no difference in terms of baseline parameters between groups. Final diagnosis was serous cystadenoma in 36.7% of patients in the group not treated with prophylaxis and in 37.7% of patients in the control group, whereas IPMN and mucinous cystadenoma were diagnosed in 3 (6.1%) and 16 (32.6%) versus 6 (6.1%) and 32 (32.6%) patients in the two groups, respectively (p = 0.23). Overall, the adverse event rate was 6.1% in the group not treated with antibiotic prophylaxis and 5.1% in the control group (p = 0.49). Only a single infectious adverse event occurred in each group (p = 0.48). The diagnostic yields were 89.7% and 90.8% in the two groups (p = 0.7), and the diagnostic accuracy rate was 81.6% in both groups (p = 1.0). Conclusions: Prophylactic antibiotics do not seem to influence the risk of infection, and their routine use should be discouraged.

Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration: A Narrative Review

Considerable progress has been made recently in the use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to diagnose intra-luminal gastrointestinal lesions and extra-luminal lesions near the gastrointestinal tract. Numerous reports have indicated that EUS-FNA has high diagnostic performance and safety, which has led to the routine use of EUS-FNA and an increasing number of cases. Thus, while EUS-FNA has a low rate of complications, endoscopists may encounter these complications as the number of cases increases. Infrequent reports have also described life-threatening complications. Therefore, endoscopists should possess a comprehensive understanding of the complications of EUS-FNA, which include hemorrhage, perforation, infection, and acute pancreatitis, as well as their management. This review examines the available evidence regarding the complications associated with EUS-FNA, and the findings will be useful for ensuring that endoscopists perform EUS-FNA safely and appropriately.

Efficacy and Safety of Non-Anesthesiologist Administration of Propofol Sedation in Endoscopic Ultrasound: A Propensity Score Analysis

In spite of promising preliminary results, evidence supporting the use of non-anesthesiologist-administered propofol sedation (NAAP) in endoscopic ultrasound (EUS) procedures is still limited. The aim of this manuscript was to examine the safety and efficacy of NAAP as compared to anesthesiologist-administered propofol sedation in EUS procedures performed in a referral center. Out of 832 patients referred to our center between 2016 and 2019, after propensity score matching two groups were compared: 305 treated with NAAP and 305 controls who underwent anesthesiologist-administered propofol sedation. The primary outcome was the rate of major complications. The median age was 67 years and the proportion of patients with comorbidities was 31.8% in both groups. One patient in each group (0.3%) experienced a major complication, whereas minor complications were observed in 13 patients in the NAAP group (4.2%) and 10 patients in the control group (3.2%; p = 0.52). Overall pain during the procedure was 2.3 ± 1 in group 1 and 1.8 ± 1 in group 2 (p = 0.67), whereas pain/discomfort upon awakening was rated as 1 ± 0.5 in both groups (p = 0.72). NAAP is safe and effective even in advanced EUS procedures. Further randomized-controlled trials (RCTs) are warranted to confirm these findings.

Contrast-Enhanced Harmonic Endoscopic Ultrasound-Guided Fine-Needle Aspiration versus Standard Fine-Needle Aspiration in Pancreatic Masses: A Propensity Score Analysis

Background: Whether endoscopic ultrasound (EUS) contrast-enhanced fine-needle aspiration (CH-EUS-FNA) determines superior results in comparison to standard EUS-FNA in tissue acquisition of pancreatic masses remains unclear. The aim of this study was to compare these two techniques on a series of patients with solid pancreatic lesions. Methods: 362 patients underwent EUS-FNA (2008–2019), after the propensity score matching of two groups were compared; 103 treated with CH-EUS-FNA (group 1) and 103 with standard EUS-FNA (group 2). The primary outcome was the diagnostic accuracy. Secondary outcomes were sensitivity, specificity, and sample adequacy. Results: Diagnostic sensitivity was 87.6% in group 1 and 80% in group 2 (p = 0.18). The negative predictive value was 56% in group 1 and 41.5% in group 2 (p = 0.06). The specificity and positive predictive values were 100% for both groups. Diagnostic accuracy was 89.3% and 82.5%, respectively (p = 0.40). Sample adequacy was 94.1% in group 1 and 91.2% in group 2 (p = 0.42). The rate of adequate core histologic samples was 33% and 28.1%, respectively (p = 0.44), and the number of needle passes to obtain adequate samples were 2.4 ± 0.6 and 2.7 ± 0.8, respectively (p = 0.76). These findings were confirmed in subgroup analyses, conducted according to lesion size and contrast enhancement pattern. Conclusions: CH-EUS-FNA does not appear to be superior to standard EUS-FNA in patients with pancreatic masses.