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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., Competing Interests: S.F. Crinò has received speaker's fees from Steris Endoscopy. A. Larghi has provided consultancy to Pentax and Boston Scientific, and has received teaching fees from Medtronic and Boston Scientific. D. Yang has provided consultancy to Olympus, Boston Scientific, Lumendi, and Steris Endoscopy. P.V. Draganov has provided consultancy to Olympus, Boston Scientific, Cook Medical, Merit, Fujifilm, Microtech, Lumendi, and Steris. J.R. Aparicio has provided consultancy to Boston Scientific. C. Robles-Medranda has provided consultancy to Pentax Medical, Boston Scientific, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, and Mediconsgroup. A. Repici has provided consultancy to Boston Scientific and Medtronic, and has received grant support from Fujifilm. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objective: The aim of this study was to evaluate predictors of malignancy in pancreatic lesions with suspicious or indeterminate endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology., Methods: Suspicious/indeterminate EUS-FNA cytology was identified from our database. Stable imaging, benign pathology, or survival for 12 months after EUS-FNA was considered benign. Diagnosis of malignancy was based on positive pathology, local invasion/metastasis on imaging, or death within 12 months from cancer-associated causes. Univariate analysis was performed to compare variables between benign and malignant lesions. Multivariate analysis (covariates: age [<70 or ≥70], appearance [solid/cystic], size [<20 or ≥20 mm], and serum CA19-9 [<40 or ≥40]) was performed using binary logistic regression., Results: There were 81 patients with suspicious or indeterminate cytology. Final diagnosis was cancer in 55 (67.9%) of 81 (adenocarcinoma in 40/81 [49.4%], "other neoplasms" in 15/81 [18.5%]) and benign in 26 (32.1%) of 81. Univariate analysis revealed a difference in age, lesion size, solid/cystic characteristics, and serum CA 19-9 between benign and malignant lesions. Only elevated serum CA 19-9 was independently associated with a diagnosis of malignancy on multivariate analysis., Conclusions: Age, lesion size, and solid/cystic characteristics on EUS were not independently associated with cancer. Pancreatic lesions with suspicious/indeterminate cytology and elevated serum CA 19-9 should be considered as concerning for a malignant diagnosis.

Background: The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated., Objective: To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions., Design: Prospective, long-term follow-up, paired design cohort study., Setting: Tertiary center., Patients: Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions., Interventions: Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps., Main Outcome Measurements: Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer)., Results: A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing (P < .0001) and standard forceps biopsy (P = .0215)., Limitations: Potential for selection bias., Conclusions: Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. (, Clinical Trial Registration Number: NCT01227382.)., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Cystic neoplasms of the pancreas are increasingly recognized because of expanding use and improved sensitivity of cross-sectional imaging studies. Major advances in the last decade have led to an improved understanding of the various types of cystic lesions and their biologic behavior. Despite significant improvement in imaging technology and the advent of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) the diagnosis and management of pancreatic cystic lesions remains a significant clinical challenge. Previous "operate in all cases of pancreatic cyst" strategies have been refined and largely replaced using EUS and cyst fluid analysis as the crux for a more practical management approach. The first diagnostic step remains the differentiation between pancreatic pseudocyst and cystic neoplasm. If a pseudocyst has been effectively excluded, the cornerstone issue becomes to determine the malignant potential of the pancreatic cystic neoplasm. In most cases the correct diagnosis and successful management is based not on a single test but on incorporating data from various sources including patient history, radiologic studies, endoscopic evaluation, in particular EUS, and cyst fluid analysis obtained during fine-needle aspirate. This review focuses on describing the various types of cystic neoplasms of the pancreas and their malignant potential, and provide the clinician with a comprehensive diagnostic approach.

Cystic neoplasms of the pancreas are increasingly recognized due to the expanding use and improved sensitivity of cross-sectional abdominal imaging. Major advances in the last decade have led to an improved understanding of the various types of cystic lesions and their biologic behavior. Despite significant improvements in imaging technology and the advent of endoscopic-ultrasound (EUS)-guided fine-needle aspiration, the diagnosis and management of pancreatic cystic lesions remains a significant clinical challenge. The first diagnostic step is to differentiate between pancreatic pseudocyst and cystic neoplasm. If a pseudocyst has been effectively excluded, the cornerstone issue is then to determine the malignant potential of the pancreatic cystic neoplasm. In the majority of cases, the correct diagnosis and successful management is based not on a single test but on incorporating data from various sources including patient history, radiologic studies, endoscopic evaluation, and cyst fluid analysis. This review will focus on describing the various types of cystic neoplasms of the pancreas, their malignant potential, and will provide the clinician with a comprehensive diagnostic approach.

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block (CPB) or neurolysis (CPN). Originally performed by anesthesiologists and radiologists via a posterior approach, recent advances in endoscopic ultrasonography (EUS) have made this technique an attractive alternative. EUS guided celiac plexus block/neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported, but larger studies are needed to confirm this finding. At this time, the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.