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Background Contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) can visualize necrotic areas and vessels inside lesions. CH-EUS findings combined with EUS-guided fine-needle aspiration (EUS-FNA) improves diagnosis in pancreatic solid masses. CH-EUS can also guide EUS-FNA (CH-EUS-FNA), potentially improving the diagnostic rate of EUS-FNA, but such superiority has not been proved in prospective studies. We aimed to assess whether CH-EUS-FNA is superior to standard EUS-FNA for specific diagnosis of solid pancreatic masses and what factors affect the diagnostic rate. Methods This randomized controlled study in one tertiary medical academic center included patients with suspected pancreatic solid masses on transabdominal ultrasound or computed tomography (CT) scan. Two passes with a 22-G standard FNA needle were done using EUS-FNA and CH-EUS-FNA in random order, and the visible core obtained was sent for histological analysis. Final diagnosis was based on EUS-FNA or surgical specimen results and on 12-month follow-up by imaging. Results 148 patients were evaluated. EUS-FNA and CH-EUS-FNA showed diagnostic sensitivities of 85.5 % and 87.6 %, respectively (not significantly different) and the combined sensitivity of the two passes was 93.8 %. The false-negative rate was not significantly different when hypoenhanced or hyperenhanced lesions were compared with the EUS-FNA results. No differences were seen for the results related to location, size, tumor stage, chronic pancreatitis features, or presence of biliary plastic stent. Conclusions The diagnostic rates for samples obtained using 22-G needles with standard EUS-FNA and CH-EUS-FNA were not statistically significantly different.

Elastography endoscopic ultrasound (E-EUS) has been proved to be a valuable supplement to endoscopic ultrasound fine-needle aspiration (EUS-FNA) in differentiating solid pancreatic lesions, but the improvement of EUS-FNA guided during E-EUS has not been proven. Our study aimed to evaluate whether E-EUS fine-needle aspiration (E-EUS-FNA) was superior to B-mode EUS-FNA for the diagnosis of solid pancreatic masses and whether the diagnostic rate was affected by specific factors. Our prospective study was conducted between 2019–2020 by recruiting patients with solid pancreatic masses. E-EUS examination was followed by one pass of E-EUS-FNA towards the blue part of the lesion and a second pass of EUS-FNA. The final diagnosis was based on surgery, E-EUS-FNA or EUS-FNA results, or a 12-month follow-up. Sixty patients with solid pancreatic lesions were evaluated. The sensitivity, specificity, and accuracy for diagnosing malignancy using E-EUS-FNA and EUS-FNA were 89.5%, 100%, 90%, 93%, 100%, and 93.3%, respectively, but the differences were not significant. Neither mass location nor the lesion size influenced the results. The lengths of the core obtained during E-EUS-FNA and EUS-FNA were similar. E-EUS-FNA in solid pancreatic lesions was not superior to B-mode EUS-FNA.

Background and Aims: The fully-covered, lumen apposing metal stents are designed for one step placement, facilitating the direct endoscopic necrosectomy into the walled-off pancreatic necrosis. However, the prediction of the number of necrosectomy sessions in these patients is not known. This study evaluated the association between the proportion of solid necrotic material inside walled-off necrosis, as assessed during the endosonography placement of a lumen apposing metal stent, and the number of necrosectomies subsequently required. Methods: Patients from three tertiary medical centers with symptomatic walled off pancreatic necrosis (pain, infection, gastric/biliary obstruction) at more than 4 weeks after onset of acute pancreatitis were retrospectively analysed. Proportion of solid necrotic debris was estimated during endosonography procedure of lumen apposing metal stents placement. Necrosectomy was performed when obstruction or inflammation occurred subsequently. Lumen apposing metal stents were removed after clearance of necrotic content. Results: In 46 patients with successful lumen apposing metal stents placement, necrosectomy was performed in 39 patients (72.78%). Performance of 3 or more necrosectomies was significantly associated with more than 50% pancreatic necrosis (p=0.032), but not with walled-off pancreatic necrosis size or location. Necrotic infection during lumen apposing metal stents stenting was associated with hypoalbuminemia, but not with necrosectomy requirement. Clinical success after a median follow-up of 13.37 months was 87%. Conclusions: Walled-off pancreatic necrosis with more than 50% solid necrotic content were associated with more necrosectomy procedures, requiering longer endoscopy time, intravenous sedations, and higher costs.

Background Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is important for the differential diagnosis of solid pancreatic lesions. Sample adequacy is related to the number of needle passes, and European guidelines recommend three to four needle passes with a standard EUS-FNA needle. We aimed to evaluate the optimal number of passes with standard EUS-FNA needles in solid pancreatic lesions. Methods Patients with solid pancreatic masses without cystic component >20% on computed tomography scan, and without biliary metallic stents, or coagulation problems were included prospectively. Standard 22G needles were used (maximum four passes); each sample was paraffin-embedded and analyzed separately. Final diagnosis was established by EUS-FNA, repeat EUS-FNA, surgery, or follow-up. Results Sixty-one of 65 patients were included. The final diagnoses were adenocarcinoma (n = 44, 72%), neuroendocrine tumor (NET) (n = 10, 16%), metastasis (n = 1, 4%) and nonmalignant lesion (n = 6, 10%). Immunohistochemical staining was possible in 17 cases. The diagnosis was established by the first pass in 62% of cases (n = 38), by the second in 15% (n = 9), by the third in 15% (n = 9), and by the fourth in 3% (n = 2). The diagnostic accuracy for all four passes compared to the first three passes was 95% vs 92% (P = .5). The contribution of the fourth pass was not different between adenocarcinoma and NET (2% vs 10%, respectively; P = .667). Conclusion Three passes with standard EUS-FNA was optimal for a specific diagnosis of solid pancreatic masses, regardless of the histological type of the lesion.

Background & Aim: Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are considered good tools for the diagnosis of pancreatic cancer and for obtaining material for cytology or histology. The accuracy of EUS-FNA can rise to 85-95%, but it is lower in cases with a chronic pancreatitis background or with previous biliary stenting. We aimed to establish the diagnostic yield of the visible length of the core biopsy samples in pancreatic cancer by using one single type of standard 22G needle and to evaluate the factors which can influence the results. Method: EUS-FNA was performed by using a 22G standard needle on patients prospectively recruited with the suspicion of pancreatic masses on transabdominal ultrasound or CT scan over a period of eight months. The number of passes was limited by the length of the core obtained. The final diagnosis was based on EUS-FNA or hepatic biopsy for their metastasis or by follow up every three month by imaging methods. Results: The study included 118 patients. Previous stents were present in 10 patients and chronic pancreatitis features were found in 3 patients. The procedure sensitivity was 89% and the global accuracy was 89%. The presence of biliary stents did not impede the accuracy of results. The number of passes did not influence the results. Conclusions: The diagnostic rate of core biopsy by using 22G needles had a high accuracy and it is safe when the length of core dictates the number of passes. The presence of biliary stents did not influence the results. Abbreviations: AUC: area under the curve; EUS: endoscopic ultrasonography; EUS-FNA: fine needle aspiration under endosonographic guidance; FNA: fine needle aspiration; INR: international normalised ratio; OR: odds ratio.