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BACKGROUND: Carcinoembryonic antigen (CEA) in the pancreatic cystic fluid is the most important biomarker for differentiating mucinous from non-mucinous pancreatic cystic lesions (PCLs). However, recent studies have shown that glucose levels in pancreatic cystic fluid can discriminate mucinous from non-mucinous cysts. AIMS: To perform a meta-analysis to determine the utility of intracystic fluid glucose of pancreatic mucinous cysts compared with intracystic CEA. METHODS: We conducted a systematic review of the literature in the PubMed, OVID Medline, and Cochrane databases. This meta-analysis considers studies published up to October 2020. RESULTS: Six studies comprising 506 patients were selected; 61.2% of the population was female. Of the 480 PCLs, 287 (59.7%) were mucinous. Pooled sensitivity and specificity of cystic fluid glucose levels for mucinous PCLs were 91% and 85%, respectively. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 6.33 and 0.11, respectively. Pooled diagnostic odds ratio (DOR) was 60.94. The pooled area under the summary receiver operating characteristic (SROC) curve was 0.959. Pooled sensitivity and specificity of pancreatic cystic fluid CEA levels were 61% and 93%. The PLR and NLR were 8.51 and 0.40, respectively. Pooled DOR was 23.52, and the pooled area under the SROC curve was 0.861. CONCLUSION: Glucose has become a useful method and appears to be better than CEA for differentiating between mucinous PCLs and non-mucinous PCLs. We suggest that the analysis of glucose in PCLs be routinely performed for the differential diagnosis of these lesions.

Introduction: Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis (PEP) is ERCP most frequent complication. Predicting PEP risk can be determinant in reducing its incidence and managing patients appropriately, however, studies conducted so far identified single risk factors with standard statistical approaches, with limited accuracy. Aims & Methods: The aim was to build and evaluate performances of machine learning models to predict PEP probability and identify relevant features. The “STARK project” is an international, multicenter, prospective cohort study focused on PEP-associated factors. Data were randomly split in training (80%) and test set (20%). Models used to predict PEP probability were: gradient boosting (GB) and logistic regression (LR). On the training set, a 10-split random cross-validation (CV) was applied to optimize parameters to obtain the best mean Area Under the Receiver Operating Characteristics Curve (AUC of ROC). Afterwards, the model was re-trained on the whole training set with the best parameters and then applied on the test set. Results: 1, 150 patients were included. 70 (6.1%) patients developed PEP. GB model AUC in CV was 0.7±0.076 (95% CI 0.64-0.76), LR model 0.585±0.068 (95% CI 0.53-0.63) (p-value=0.012). AUC in test for GB model was 0.671. Most relevant variables for PEP prediction were: total bilirubin, age, body mass index, procedure time, alcohol units/day, previous sphincterotomy, biliary cannulation attempts and use of Ringer’s solution. Conclusion: This is the first study applying machine learning techniques for PEP prediction, with GB significantly outperforming LR model. Relevant variables were mostly pre-procedural except for procedure time, biliary cannulation attempts and Ringer’s solution use.

in view of the advances made over the past few years, digestive endoscopy units must adapt to an increased demand and the development of novel techniques. However, the actual status of these units is virtually unknown and is limited to few surveys from over a decade ago. Thus, a new survey was performed of the current situation of endoscopy units in the Valencian Community.

Background and study aims :The aim of this study was to assess the efficacy and safety of endoscopic ultrasound-guided rendezvous (EUS-RV) for benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire. Patients and methods :Patients who underwent EUS-RV after failed biliary or pancreatic cannulation for benign disorder were candidates for this study. For EUS-RV, a 22-gauge needle and a 0.018-inch guidewire were used. Inclusion criteria were unsuccessful biliary or pancreatic cannulation for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with benign biliary or pancreatic obstruction. Exclusion criteria included malignant biliary or pancreatic obstruction, inaccessible papilla due to surgically altered upper gastrointestinal anatomy or duodenal stricture, and previous sphincterotomy and/or biliary stent placement. The primary outcome was the technical success rate of biliary or pancreatic cannulation, and the secondary outcome was the rate of adverse events. Results :Thirty-one patients were evaluated. The overall technical success rate was 80.6 % (81.5 % in biliary and 75 % in pancreatic cases). Adverse events (AEs) were identified in 12.9 % of patients, including one with biliary peritonitis, one with abdominal pain and one with severe pancreatitis plus pneumomediastinum. Only one of the AEs (3.3 %) was directly related to the rendezvous procedure. Conclusions :EUS-RV may be a safe and feasible salvage method for unsuccessful cannulation for benign disorders. Use of a 22-gauge needle with a 0.018-inch guidewire may be the first option for benign pathology.

Over-the-scope clip (OTSC) has been reported to control non-variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC 'type a' with a cap of 11 mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child-Pugh score =8) and portal hypertension (hepatic venous pressure gradient, mean 14.4 ± 1.3 mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip-related adverse events during a 30-day follow-up period. Two patients developed solid food dysphagia after 3 months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.

Purpose: Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) acute pancreatitis (PEP) is ERCP most frequent complication. Predicting PEP onset risk can be determinant in reducing its incidence. However, studies conducted so far identified single risk factors that have never been used together to predict the risk effectively. The aim of this study was to build a mathematical model to predict PEP probability through machine learning techniques. Materials and methods: “STARK project” is an international, multicenter, prospective cohort study developed within Pancreas 2000 Educational Program, carried out in 7 tertiary centers enrolling patients undergoing ERCP. Patients enrolled were followed-up to detect PEP. The data was randomly split in training set (80%) and test set (20%). Two models were used to predict PEP probability: gradient boosting (GB) and logistic regression (LR). On both models the same data preparation and the same following procedure was applied: on the training set, a 10- split random cross-validation (CV) was applied to optimize parameters in order to obtain the best mean Area Under the Receiver Operating Characteristics Curve (AUC of ROC). Afterwards, the model was re-trained on the whole training set with the best parameters and then applied on the test set. Results: 1, 150 patients were included. 70 (6.1%) patients developed PEP. GB model retrieved a AUC in CV of 0.7±0.076 with 95% CI 0.64-0.76 ; LR model retrieved a AUC in CV of 0.585±0.068 with 95% CI 0.53-0.63. The statistical comparison between the two models in CV retrieved a p value of 0.01. AUC in test for the GB model was 0.671, confirming the stability of the model. Model most relevant variables for the prediction of PEP were: total bilirubin level, age, body mass index, procedure time, units of alcohol/day, previous sphincterotomy, attempts of biliary cannulation, use of Ringer Lactate. Conclusions: This is the first study applying machine learning techniques for the prediction of PEP, with the GB model showing a significantly better performance than the LR model. The most relevant variables we observed were mostly pre- procedural variables except for the procedure time, attempts of biliary cannulation, use of Ringer Lactate.

AIMS: To assess the expression of cathepsins in pancreatic samples obtained by endoscopic ultrasonography and fine needle aspiration (EUS-FNA) and to investigate their relationship with the staging of the pancreatic ductal adenocarcinoma (PDAC). METHODS: We prospectively included patients with solid pancreatic masses, in which EUS-FNA were performed. Cathepsins B, L, S and H expression was determined in FNA samples. RESULTS: Seventeen FNA were performed. All cytological material was from PDAC. Expression of cathepsins was predominantly low (B 65%, L 23%, S 76%, and H 41%). We found no correlation between the expression levels and the extension of the neoplasm. CONCLUSION: Expression of cathepsins in the cytological material of PDAC is diverse but still poor to be useful in the pre-operative diagnosis. There is no correlation between the expression levels of cathepsins and the extension of the PDAC.