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Gastrointestinal varices are present in about half of patients with portal hypertension (PH). While most patients with PH have liver cirrhosis, it can also develop in the absence of cirrhosis, i.e. ‘non-cirrhotic PH’. Acute variceal bleeding is the most serious complication of PH, occurring in one third of patients with gastrointestinal varices, with an increased mortality of up to 20% at 6 weeks in patients with decompensated liver cirrhosis. The present chapter reviews the endoscopic therapeutic options for patients with gastric and ectopic gastrointestinal varices.

Direct endoscopic necrosectomy (DEN) is a cumbersome, time-consuming procedure that can be necessary in cases of infected pancreatic walled-off necrosis (WON) not responding to endoscopic ultrasound (EUS)- guided drainage only. Until now, DEN has been performed with non-dedicated devices, thus requiring multiple, long-lasting sessions to achieve adequate clearance of necrotic content. These results in prolonged hospital stay, increased costs and have potential consequences for patients who must undergo multiple endoscopic interventions under sedation. We report four cases of DEN performed in patients with WON after EUS-guided drainage with the Endorotor system, a new morcellator device specifically designed to perform the procedure.

We recently introduced a series of papers "What should be known prior to performing EUS exams." In Part I, the authors discussed which clinical information and whether other imaging modalities are needed before embarking EUS examinations. In Part II, technical controversies on how EUS is performed were discussed from different points of view. In this article, important practical issues regarding EUS elastography will be raised and controversially discussed from very different points of view.

Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field. Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers. Results: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50–200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended. Conclusion: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures.

We recently introduced a series of articles that dealt with controversies in EUS. In Part I, the authors discussed which clinical information is necessary prior to EUS and whether other imaging modalities are required before embarking on EUS examinations. Part II focuses on technical details and controversies about the use of EUS in special situations. In this article, important practical issues regarding the application of contrast-enhanced EUS in various clinical settings are raised and controversially discussed from different points of view.

OBJECTIVES Studies on endoscopic treatment of non-anastomotic biliary strictures (NABS) following orthotopic liver transplantation (OLT) are scanty and with a short follow-up. The long-term results of endoscopic treatment with plastic stents of NABS following OLT were analyzed. METHODS Retrospective analysis of consecutive enrolled patients who underwent endoscopic treatment for NABS after OLT between 1997 and 2015. Endoscopic treatment success was defined as stricture resolution, without recurrence. RESULTS During the study period, 33 patients with NABS underwent endoscopic retrograde cholangiopancreatography (ERCP) in our center. A total of 68 ERCP were performed with a 4.4% of procedure-related adverse events. Mortality related to cholangitis secondary to endoscopic procedures was 12%. After median follow-up of 70.3 months from stents removal, NABS resolution was obtained in 12 out of 24 (50%) patients. Only one case of late NABS recurrence was observed which was successfully retreated endoscopically. According to our data analysis NABS occurring

Carcinoma of the ampulla of Vater is an uncommon neoplasm and represents 0.5% of all gastrointestinal malignancies, being less common than carcinoma of the pancreas and bile ducts. The most common ampullary tumor is the adenocarcinoma with tubular growth pattern. Signet ring cell carcinoma is extremely rare. In this article, we report a case of signet ring cell carcinoma of the ampulla of Vater showing focal neuroendocrine amphicrine differentiation and intestinal phenotype, which occurred in a 49-year-old male who is still alive 7 years after surgery, without evidence of recurrence. This long-term survival might be attributed not only to the early stage of the disease but also to the neuroendocrine differentiation and the absence of genetic alterations.

In the last few years, the diagnostic and therapeutic utilization of endoscopic ultrasound (EUS) for a variety of liver conditions has exponentially grown. We performed a thorough search for all available studies on the performance of diagnostic and therapeutic EUS in the field of hepatology. This article reviews the indication of EUS in the evaluation and treatment of portal hypertension, portal vein pressure measurement, focal liver lesions, and parenchymal liver diseases, and presents all the clinical evidences available so far in this regard. All the review data suggest that EUS is becoming an increasingly important tool in the armamentarium of the hepatologists for the management of certain liver-related conditions. Implementation in the education of the hepatologists of means to become more familiar with both diagnostic and therapeutic capabilities of EUS is warranted.

Background and study aims We report our experience in endoscopic ultrasound-guided gallbladder drainage performed emergently in 4 prohibitive surgical risk patients with concurrent coagulopathy or on anticoagulant therapy using an electrocautery enhanced lumen apposing self expanding metal stent (LA-SEMS).

When endoscopic retrograde cholangiopancreatography (ERCP) fails to decompress the biliary system or the pancreatic duct, endoscopic ultrasonography (EUS)-guided biliary or pancreatic access and drainage can be used. Data show a high success rate and acceptable adverse event rate for EUS-guided biliary drainage. The outcomes of EUS-guided biliary drainage seem equivalent to percutaneous drainage and ERCP, whereas only retrospective studies are available for pancreatic duct drainage. In this article, revision of the technical and clinical status and the current evidence of interventional EUS-guided biliary and pancreatic duct access and drainage are presented.

Background and Aims: The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE. Methods: A noninferiority study (noninferiority margin, 5%) was conducted at 14 centers in 8 countries. Patients with SPLs requiring tissue sampling were randomly assigned (1:1) to undergo EUS-FNB with or without ROSE using new-generation FNB needles. The touch-imprint cytology technique was used to perform ROSE. The primary endpoint was diagnostic accuracy, and secondary endpoints were safety, tissue core procurement, specimen quality, and sampling procedural time. Results: Eight hundred patients were randomized over an 18-month period, and 771 were analyzed (385 with ROSE and 386 without). Comparable diagnostic accuracies were obtained in both arms (96.4% with ROSE and 97.4% without ROSE, P = .396). Noninferiority of EUS-FNB without ROSE was confirmed with an absolute risk difference of 1.0% (1-sided 90% confidence interval, –1.1% to 3.1%; noninferiority P < .001). Safety and sample quality of histologic specimens were similar in both groups. A significantly higher tissue core rate was obtained by EUS-FNB without ROSE (70.7% vs. 78.0%, P = .021), with a significantly shorter mean sampling procedural time (17.9 ± 8.8 vs 11.7 ± 6.0 minutes, P < .0001). Conclusions: EUS-FNB demonstrated high diagnostic accuracy in evaluating SPLs independently on execution of ROSE. When new-generation FNB needles are used, ROSE should not be routinely recommended. (ClinicalTrial.gov number NCT03322592.)

Background and aim Endoscopic ultrasonography guided-celiac plexus neurolysis relieves pain in patients with pancreatic cancer but with often suboptimal and transient results. The study aims to compare the efficacy and safety of endoscopic ultrasound-guided tumor ethanol ablation combined with celiac plexus neurolysis with respect to celiac plexus neurolysis alone for pain management in patients with pancreatic cancer. Methods Among 123 patients with unresectable pancreatic cancer referred to our Institution between 2006 and 2014, 58 treated with endoscopic ultrasound-guided celiac plexus neurolysis (Group 1) and 65 with the combined approach (Group 2) were compared. Logistic regression models were applied to identify predictors of pain relief. Results The two groups presented similar baseline clinical and tumoral parameters. Pre-procedural visual analog scale score was 7 in both groups (P = 0.8), and tumor max diameter was 38 mm (range 25-59) in Group 1 and 43 mm (22-59) in Group 2 (P = 0.4). The combined treatment increased pain relief and complete pain response rate (P = 0.005 and 0.003, respectively). Median duration of pain relief was 10 (7-14) and 18 (13-20) weeks in the two groups, respectively (P = 0.004). At multivariate regression, initial visual analog scale score and endoscopic technique adopted resulted significantly associated with pain relief. No severe treatment-related adverse events were reported. Median overall survival was 6.5 months (5.1-8.6) in Group 1 and 8.3 months (6-11.4) in Group 2 (P = 0.05). Conclusions Endoscopic ultrasound-guided tumor ablation combined with celiac plexus neurolysis appears to be superior to celiac plexus neurolysis alone in terms of pain control and overall survival.

Background Recently, a novel lumen-apposing fully covered self-expanding metal stent (LA-FCSEMS) mounted on an electrocautery-enhanced delivery system has been developed to perform endoscopic ultrasound (EUS)-guided transluminal drainage. From early experience, however, release of the proximal flange of the stent has mostly been done using endoscopic view guidance to ensure proper positioning. Aim We describe a new technique that we have named the Intra-Channel Stent Release Technique (ICSRT) to perform stent placement under complete EUS control, without the use of either fluoroscopic or endoscopic views. Material and methods Data on all consecutive patients who underwent EUS-guided drainage using the new ICSRT between June 2014 and April 2016 were retrospectively retrieved from two institution databases. All EUS procedures were performed by experienced endoscopists with the patient under conscious or deep sedation. The total procedure and stent deployment time, and adverse events related to stent positioning with the ICSRT were evaluated. Results One hundred consecutive patients (51 women; mean age ± SD, 66 ± 15.2 years, range 34 – 95) underwent EUS-guided transluminal drainage with the Hot AXIOS™ device using the new ICSRT. The procedure was technically successful in all but one patient (1 %). The mean total procedural time was 21.9 minutes (range 7 – 50), while the mean time for stent placement was 3.2 minutes (range 1 – 15). No major adverse events occurred. Discussion The ICSRT has been used to deploy the newly developed lumen-apposing FCSEMS under complete EUS guidance without fluoroscopic and/or endoscopic assistance. The technique appears to be safe and highly effective and should be learned by all interventional endosonographers in order to be able to perform drainage in all clinical scenarios.

Pancreatic neuroendocrine neoplasms (PanNENs) are rare tumors, but their incidental diagnosis has significantly increased due to the widespread use of imaging studies. Therefore, most PanNENs are now diagnosed when completely asymptomatic and in early stages. PanNENs are classified according to their grade (Ki-67 index) and can be functional (F-) or nonfunctional (NF-) depending on the presence or absence of a clinical, hormonal hypersecretion syndrome. The mainstay treatment of PanNENs is a surgery that is mostly curative but also associated with significant short- and long-term adverse events. Therefore, less invasive alternative locoregional treatment modalities are warranted. Recently, few case reports and two case series have described EUS-guided radiofrequency ablation (EUS-RFA) for the treatment of patients with both F-PanNENs and NF-PanNENs. If for F-PanNENs EUS-RFA can very easily become the standard of care, for NF-PanNENEs it is still controversial how to select patients for EUS-RFA. A balance between overtreatment (i.e., RFA/surgery in patients who will not progress) and undertreatment (locoregional treatments in patients with undetected metastases) needs to be found based on solid data. The decision should also take into account patients' comorbidity and risk of postoperative death, life expectancy, tumor location, risk of postoperative fistula and postoperative morbidity, and risk of long-term exocrine and/or endocrine insufficiency. To answer the important question on which a patient should be treated with EUS-RFA, properly designed studies to evaluate the efficacy of this treatment in large cohorts of patients with NF-PanNENs and to establish prognostic factors associated with treatment response are urgently needed.

Background Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. Methods Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. Results 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. Conclusions Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.

Background and Objective: EUS-guided fine-needle biopsy has become the standard for tissue sampling. A new 20G ProCore™ (PC) needle has been developed to overcome the limitations of tissue acquisition of the smaller needles (22G, 25G) and the rigidity of the larger one (19G). The aim of this study is to assess the performance of the 20G PC needle. Materials and Methods: Patients who underwent EUS-guided tissue acquisition with the 20G PC needle of pancreatic and extra-pancreatic mass lesions were retrospectively identified at three Italian centers (Bologna, Fermo, and Palermo). Diagnostic adequacy, accuracy, and tissue core acquisition were the outcome measures. All the cases were performed without rapid on-site evaluation. Results: A total of 384 patients with pancreatic (62.2%) and extra-pancreatic lesions were included in the study. For pancreatic lesions, adequacy, accuracy, sensitivity, and specificity were 92.4%, 91.5%, 90.8%, and 100%, respectively, with a number needed to misdiagnose (NNM) of 11.8. The tissue core was obtained in 72% of cases. Transduodenal approach was performed in 150 pancreatic lesions; adequacy, accuracy, and tissue core acquisition were 88.7%, 90%, and 66%, respectively (NNM 10). For extrapancreatic lesions, adequacy, accuracy, sensitivity, specificity, and tissue core sampling were 95.3%, 95.3%, 92.6%, 100%, and 84.5% (NNM 21.3). Conclusions: The 20G PC needle showed high diagnostic adequacy and accuracy, regardless the access route.

Background No study has compared the performance of light microscopy (LM) and whole slide imaging (WSI) for endoscopic ultrasound (EUS) histological acquired tissue samples from pancreatic solid lesions (PSLs). We evaluated the concordance between LM and WSI and the inter- and intra-observer agreements among pathologists on PSLs EUS acquired samples. Methods LM and WSI from 60 patients with PSLs were evaluated by five expert pathologists to define: diagnostic classification, presence of a core, number and percentage of lesional cells. Washout period between evaluations was 3 months. Time of the procedures was also assessed. Results Forty-eight cell-block and 12 biopsy samples were evaluated. A high concordance between LM and WSI was found. Inter- and intra-observer agreements for diagnostic classification were substantial and complete, respectively. For all the other parameters, the inter-observer agreement was usually higher for LM. For the intra-observer, a substantial agreement was reached regarding the presence of tissue core and the number and the percentage of malignant cells. Median time for performing LM was significantly shorter than for WSI (p Conclusions LM and WSI of cell-block and biopsy samples acquired by EUS in PSLs were highly concordant, with a substantial inter-observer and a complete intra-observer agreements regarding diagnostic classification.

EUS-guided through-the-needle biopsy (TTNB) sampling has been reported to improve diagnostic yield compared with cytology for the evaluation of pancreatic cystic lesions (PCLs). The number of macroscopically visible tissue samples needed to reach an adequate diagnosis is still unknown.This is a retrospective, single-center study on consecutive patients with PCLs with risk features (cyst3 cm, thickened wall, cyst growth during follow-up, and mural nodules) who underwent TTNB sampling. The capability of differentiating mucinous versus nonmucinous cysts, ability to obtain a cyst-lining epithelium, definition of the grade of dysplasia, and specific diagnosis of cyst histotype were evaluated for 1, 2, or 3 TTNB macroscopically visible specimens.Sixty-one patients were evaluated. A 100% histologic adequacy was reached by 2 samples (P = .05 versus 1). Compared with cytology, 1 TTNB specimen improved the possibility of defining cyst histotype (P .0001), whereas 2 specimens increased all 4 diagnostic categories (P .003). Two specimens also increased diagnostic yield compared with 1 sample (P .085). The collection of a third sample did not improve the value of any diagnostic categories. A specific diagnosis was reached in 74% of patients with 2 histologic samples. The diagnostic reliability of TTNB sampling compared with surgical histology was 90%, with a 22.9% rate of adverse events.Two TTNB macroscopically visible specimens reached 100% histologic adequacy and a specific diagnosis in 74% of patients. The collection of a third specimen did not add any additional information and should be avoided to possibly decrease the risk of adverse events.

Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle.Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders.A total of 608 patients were allocated to FNA (n = 306) or FNB (n = 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P = .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P .001), accuracy for malignancy (87% vs 78%, P = .002) and Bethesda classification (82% vs 72%, P = .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P = .004), and did not differ among centers (P = .836).The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

Background Rapid on-site evaluation (ROSE) of cytological specimensacquired with EUS-guided fine needle aspiration (EUS-FNA) represents the most accurate available technique to reach a definitive diagnosis in patients with pancreatic solid masses. Recently, needles with high histological yield have been developed for EUS-guided fine needle biopsy (EUS-FNB), with which the need for ROSE can be potentially overcome. Aims The primary aim is to compare the diagnostic accuracy of EUS-FNB with or without ROSE. The main endpoint will be measured against the gold standard diagnosis (surgical pathology whenever available or diagnostic work-up in agreement with a clinical course of at least six months). Secondary endpoints include: (a) safety; (b) presence of tissue core; (c) quality of specimens; (d) time of the sampling procedure. Reliability of macroscopic on-site evaluation (MOSE) by endosonographers will be also assessed. Methods FROSENOR is an international randomized non-inferiority ongoing study at sixteen centers in four continents. Eight hundred patients will be randomized in two arms (EUS-FNB + ROSE vs. EUS-FNB alone) and outcomes compared. Sample size has been calculated in order to demonstrate the non-inferiority of FNB alone. Randomization and data collection will be performed online. Discussion This study will ascertain if ROSE is still needed when performing EUS-FNB of solid pancreatic lesions.

Leaks/dehiscence of the enteral stump associated with infected peri-enteric collections after upper gastrointestinal surgery are a life-threatening adverse event, not usually endoscopically treatable.We describe a new endoscopic approach to treat complex entero-cutaneous fistulas (CECF) by creating a “suction room” through placement of multiple stents (enteral, biliary and/or pancreatic) and a large nose-enteral suction tube inside the enteral stent maintained on a continuous negative aspiration suction.Between January 2016 and December 2019, six consecutive patients referred to our unit with CECF of the enteral stump after failed redo surgeries underwent creation of a “suction room.” In five patients, enteral, biliary and pancreatic stents were positioned before a nose-to-stent or nose-to-collection large 18 Fr tube placement. In one patient, a pancreatic stent was not placed. Technical and clinical success were achieved in all patients. Mean and median times of aspiration were 49 and 27 days, respectively, with a mean hospital stay of 56 days after the endoscopic procedure. Stents were successfully removed. Mean post-procedural follow-up was 17.3 months.Endoscopic creation of the “suction room” offers the unique possibility of treating complex entero-cutaneous fistulas in surgically altered sites, which are difficult to manage with standard endoscopic methods.

Background The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion. Patients and methods All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed. Results A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases. Conclusions MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion., Highlights • Few evidences are present on the impact of the multidisciplinary tumor board (MDTB) on pancreatic cancer (PC) management • We documented a discrepancy rate of 23.7% between the pre- and post-MDTB discussion. • This underlines the fundamental role of the MDTB in PC management.

We present here a new chapter of the series of papers on how to perform specific EUS techniques. In this manuscript, we discuss on how to perform EUS-guided placement of fiducial markers in gastrointestinal tumors. The aim is to present the scientific evidence of fiducials placement before radiation therapy, including an accurate revision of the literature, to give some advices on the technical approach, and to discuss Pros and Cons from the point of view of gastroenterologists and radiation oncologist.

Background & Aims: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas have been reported to be associated with an increased risk of developing extra-pancreatic malignancies. A common genetic background has been hypothesised to be responsible for such an association. Human chromosomal region 8q24 has been associated with many types of cancer. The majority of these associations lie at approximately 128 Mb on chromosome 8. We conducted a study in order to examine the association between IPMN and single nucleotide polymorphisms (SNPs) from the 8q24 region, namely rs10505477, rs6983267, rs7014346, rs6993464, previously reported to influence general cancer susceptibility. Methods. The study was performed on 117 IPMN cases and 231 controls. Cases were enrolled at the Digestive Endoscopy Unit, Policlinico Agostino Gemelli from January, 2010 to June, 2011, with either a prevalent or incident IPMN diagnosis. Status of SNPs was determined using a StepOne Real-time PCR system (Applied Biosystems) and TaqMan SNP Genotyping Assay™ 40X. Unconditional multiple logistic regression models were used to estimate odds ratios and 95% confidence intervals for the association of selected SNPs and IPMNs. Results. Cases were more likely to report a 1st degree family history of cancer (p

The aim of this study was to compare the performance of EUS-guided fine-needle biopsy using fork-tip or side-fenestrated needles in patients with solid pancreatic lesions.A randomized controlled study was conducted in a single academic center on patients who underwent sampling with fork-tip or side-fenestrated 22-gauge or 25-gauge needles. Three passes were performed, each independently evaluated by a blinded pathologist and by endosonographers for macroscopic on-site evaluation (MOSE). The primary outcome was histologic yield; secondary aims were safety, diagnostic yield, sample quality, number of needle passes required to establish a diagnosis, and reliability of MOSE.One hundred ninety-two patients were enrolled. Both 22-gauge and 25-gauge fork-tip needles retrieved significantly higher rates of histologic samples than side-fenestrated needles (P .013). Safety and diagnostic accuracy were comparable in the 2 arms, whereas sample quality (tissue integrity and blood contamination) was significantly better in the fork-tip group (P .0001). The median number of diagnostic passes was lower using fork-tip needles (P = .054). The agreement between MOSE and pathologic evaluation was almost perfect in the fork-tip group and fair in the side-fenestrated group.Both needles showed equivalent safety and diagnostic accuracy. However, fork-tip needles provided a higher rate of extremely good-quality histologic samples and required fewer needle passes to reach a diagnosis. MOSE is a highly reliable tool when fork-tip needles are used compared with side-fenestrated needles. (Clinical trial registration number: NCT03622229.).

e19196 Background: The management of PD is very insidious, mainly due to the often difficult differential diagnosis between benign and malignant diseases, and, in case of pancreatic ductal adenocarcinoma (PDCA), to the frequently hard differentiation among resectable/borderline PDCA susceptible to upfront surgery, locally advanced PDCA susceptible to a neoadjuvant approach and never resectable or metastatic PDCA in which a palliative treatment is the only option. A correct PD evaluation and the subsequent choice of the most appropriate treatment strategy, thus, need a MA, involving surgeons, oncologists, radiologists, radiation oncologists, endoscopists, gastroenterologists and pathologists. On the basis of such considerations, we investigate the impact of the multidisciplinary meeting (MM) in the management of PD at our Institution. Methods: We retrospectively evaluated all the cases discussed by surgeons at our MM. We collected data, both pre- and post-MM, regarding diagnosis (cyst vs pancreatitis vs IPMN vs PDCA), and, in case of PDCA, tumor burden at baseline (resectable vs border-line resectable vs locally advanced vs metastatic disease) and disease response to treatment (disease control vs progression). Primary endpoint was the overall rate of discrepancy in diagnosis and/or PD evaluation between pre- and post-MM. Results: From October 2018 to December 2019, a total of 139 cases were presented by surgeons. After MM, a total of 38 diagnosis and/or PD evaluation were modified, for an overall discrepancy rate of 27%. In particular, of the 38 discordant cases, 9 (24%) were initial diagnosis, 24 (63%) baseline tumor burden assessments and 5 (13%) were PDCA response evaluations. Among the 24 cases of tumor burden evaluations, treatment strategy changed in 17 out of 24 cases. More specifically, of the 19 cases, evaluated as borderline/resectable before the MM, 15 were defined as locally-advanced or metastatic disease after the MM; of the 5 cases, evaluated as not resectable before the MM, 2 were considered border-line/resectable after the MM. Similarly, out of 9 cases of discrepant initial diagnosis, 5 cases, considered as malignant disease before MM, were assessed as benign after the MM. Conclusions: Our analysis demonstrates a significant rate of discrepancy in diagnosis and/or PD evaluation between pre- and post-MM. Our results show that a MA allows a considerable modification in PD diagnosis and evaluation, maximizing the treatment strategy, in particular avoiding unnecessary and detrimental pancreatic surgery.

Recently, we introduced a series of papers describing on how to perform certain techniques and controversies in EUS. In the first paper, “What should be known before performing EUS examinations, Part I,” the authors discussed clinical information and whether other imaging modalities should be needed before embarking in EUS examination. In Part II, some technical controversies on how EUS is performed are discussed from different points of view by providing the relevant available evidence. Herewith, we describe on how to perform EUS-guided fine needle tattooing (FNT) in daily practice. The aim of this paper is to discuss pros and cons for several issues including historical remarks, injecting material, technical approach, and how to perform EUS-FNT including argues in favor and against.

Biliary strictures represent some of the most frequent complications encountered after orthotopic liver transplantation. They comprise an array of biliary abnormalities with variations in anatomical location, clinical presentation, and different pathogenesis. Magnetic resonance cholangiography represents the most accurate noninvasive imaging test that can provide detailed imaging of the whole biliary system-below and above the anastomosis. It is of particular value in those harboring complex hilar or intrahepatic strictures, offering a detailed roadmap for planning therapeutic procedures. Endoscopic therapy of biliary strictures usually requires biliary sphincterotomy plus balloon dilation and stent placement. However, endoscopic management of nonanastomotic biliary strictures is much more complex and challenging as compared with anastomotic biliary strictures. The present article is a narrative review presenting the results of endoscopic treatment of biliary strictures occurring after liver transplantation, describing the different strategies based on the nature of the stricture and summarizing their outcomes.

OBJECTIVES We conducted a study in order to assess the prevalence of extrapancreatic malignancies (EPMs) in a cohort of patients with intraductal papillary mucinous neoplasms (IPMNs) from northeastern Italy. METHODS A study was conducted in hospital Santa Maria della Misericordia, Udine, Italy. Hospital records were screened in order to identify newly diagnosed IPMN cases in the period from January 1, 2009, to December 31, 2015. We searched for EPMs diagnosed previous to, synchronous to, or after the IPMN. The ratio of the observed (O) number of patients with EPMs to the expected (E) was calculated. RESULTS We identified 72 EPMs in 63 (31.8%) of 198 patients included. Among them, 51 (70.8%) were diagnosed previous to, 17 (23.6%) synchronous to, and 4 (5.6%) after the IPMN. Most frequently diagnosed were colorectal (12 patients [6.1%]), breast (8 patients [6.8%, in females]), renal cell (8 patients [4.0%]), and prostate cancer (7 patients [8.6%, in males]). The O/E ratios for EPMs were significantly increased for cancer in general (3.66; 95% confidence interval [CI], 2.39-5.37), renal cell (9.62; 95% CI, 1.98-28.10), prostate (4.91; 95% CI, 1.59-11.45), and breast cancer (3.16; 95% CI, 1.03-7.37). CONCLUSIONS We report an increased risk of EPMs in patients with IPMN, especially for renal cell, prostate, colorectal, and breast cancer.

Background and aim Tissue acquisition in pancreatic cystic lesions (PCL) is the ideal method for diagnosis and risk stratification for malignancy of these lesions. Direct sampling from the walls of PCL with different devices has shown better results than cytology from cystic fluid. We carried out a retrospective, multicenter study to evaluate the feasibility, safety, and diagnostic yield of a micro-forceps, specifically designed to be used through a 19-gauge needle after endoscopic ultrasonography (EUS)-guided puncture of PCL. Methods We retrospectively collected data from patients who underwent EUS-through-the-needle biopsy (EUS-TTNB) in PCL at six referral centers. Results The sampling procedure was carried out in 56 patients (mean age 57.5 ± 13.1 years, M:F 17:39), and was technically successful in all of them (100%; 95% confidence interval [CI], 94-100%). Adverse events occurred in 9/56 (16.1%; 95% CI, 8-28%) patients, with self-limited intracystic hemorrhage the most common (7/56, 12.5%; 95% CI, 5-24%). All adverse events were mild, and resolved without any specific intervention. Specimens were considered adequate for histological diagnosis in 47/56 (83.9%; 95% CI, 72-92%). In two of these patients, despite the histological adequacy, a diagnosis could not be reached. In two other cases, a specimen sufficient for a cytological diagnosis was obtained. Overall diagnostic yield by combining cytological and histological samples was 47/56 (83.9%; 95% CI, 72-92%). Conclusion EUS-TTNB with micro-forceps in PCL is feasible, safe, and has a high diagnostic yield. Future prospective studies are needed to better assess the clinical impact of EUS-TTNB on the management of PCL.

Background Endoscopic ultrasound (EUS)-guided drainage is the procedure of choice for pancreatic fluid collection (PFC) management. Recently developed lumen-apposing fully covered self-expandable metal stents (LAMSs) may facilitate drainage, especially of necrotic and complex PFCs. Objective To evaluate the feasibility and efficacy of a newly developed LAMS (Nagi, Taiwong Medical Co. Ltd, South Korea) in the drainage of PFCs. Methods Retrospective analysis of LAMS drainage of PFCs from seven centres. Patient demographic, EUS and radiological findings, PFCs aetiology, procedural technical and clinical success, and adverse events were evaluated. Results Sixty-seven patients with mean age 58.8 ± 14 years (68.7% males) were included in the analysis. Of these, 44 patients had pseudocyst (PP) and 23 patients had walled-off pancreatic necrosis (WOPN). Technical success was achieved in 98.5% of cases and clinical success in 94%. The adverse event rate was 24.2%, higher and mostly due to stent migration and occlusion in the WOPN group as compared to the PP group, despite the time to stent removal being significantly lower in the WOPN group. Conclusions PFC drainage using the Nagi stent is highly feasible and effective, with a relatively safe profile. Future studies enrolling more patients with complex PFCs are needed to clearly establish the role of this stent in PFC management.