Radiomics analysis for prediction and classification of submucosal tumors based on gastrointestinal endoscopic ultrasonography.

Objectives: To identify and classify submucosal tumors by building and validating a radiomics model with gastrointestinal endoscopic ultrasonography (EUS) images. Methods: A total of 144 patients diagnosed with submucosal tumors through gastrointestinal EUS were collected between January 2019 and October 2020. There are 1952 radiomic features extracted from each patient's EUS images. The statistical test and the customized least absolute shrinkage and selection operator regression were used for feature selection. Subsequently, an extremely randomized trees algorithm was utilized to construct a robust radiomics classification model specifically tailored for gastrointestinal EUS images. The performance of the model was measured by evaluating the area under the receiver operating characteristic curve. Results: The radiomics model comprised 30 selected features that showed good discrimination performance in the validation cohorts. During validation, the area under the receiver operating characteristic curve was calculated as 0.9203 and the mean value after 10-fold cross-validation was 0.9260, indicating excellent stability and calibration. These results confirm the clinical utility of the model. Conclusions: Utilizing the dataset provided curated from gastrointestinal EUS examinations at our collaborating hospital, we have developed a well-performing radiomics model. It can be used for personalized and non-invasive prediction of the type of submucosal tumors, providing physicians with aid for early treatment and management of tumor progression.

Sedative effects of propofol and risk factors for excessive sedation in the endoscopic treatment of biliary and pancreatic diseases.

Objectives: The safety and effectiveness of propofol in more complex endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, remain unknown. Thus, we aimed to evaluate propofol sedation during endoscopic cholangiopancreatography, ultrasound-guided intervention, and gastroduodenal stenting and examine risk factors for excessive sedation. Methods: We retrospectively analyzed data from 870 patients who underwent endoscopic treatment with propofol sedation for biliary and pancreatic disease between October 2020 and September 2021. Sedation included propofol and fentanyl, with continuous monitoring of vital signs and the bispectral index. The assessed risk factors included age, complications, body mass index, treatment duration, and specialty. Results: Distal bile duct treatment (n = 367), hilar bile duct treatment (n = 197), post-small-intestinal reconstruction treatment (n = 75), endoscopic ultrasound-guided intervention (n = 140), and gastrointestinal obstruction treatment (n = 91) were performed. The rates of excessive sedation, hypoxemia, and hypotension were 7.8%, 6.0%, and 1.8%, respectively. Post-small-intestinal reconstruction treatment had the highest incidence rate of excessive sedation (16%), whereas endoscopic ultrasound-guided intervention had the lowest incidence rate (4.3%). Multivariate analysis revealed significant associations between excessive sedation and comorbid sleep apnea, obesity, and prolonged procedural time. Conclusions: Obesity, sleep apnea syndrome, and prolonged procedure time are risk factors for excessive sedation related to propofol use. Thus, sedation techniques should be tailored for these patients.

The outcomes of endoscopic ultrasound-guided tissue acquisition for small focal liver lesions measuring ≤2 cm.

Objectives: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) for focal liver lesions has gained attention as an alternative to percutaneous biopsy. Although the outcomes of EUS-TA for focal liver lesions have been reported to be favorable, no studies have focused on small focal liver lesions (≤2 cm). The aim of this study was to evaluate the outcomes of EUS-TA for small focal liver lesions (≤2 cm). Methods: The details of EUS-TA performed for focal liver lesions between 2016 and 2022 were retrospectively reviewed. The outcomes were compared between cases involving ≤2 cm lesions and those involving >2 cm lesions. The primary outcomes were diagnostic ability and adverse events. Results: EUS-TA for focal liver lesions was performed in 109 cases. Of the 109 cases, 32 (29.3%) involved ≤2 cm lesions and 77 (70.6%) involved >2 cm lesions. Right lobe lesions and transduodenal puncture were significantly fewer in the ≤2 cm group. There were no significant differences in needle gauge, needle type, or number of punctures between the groups. The sensitivity, specificity, and accuracy rates were 96.8%, 100%, and 96.8%, respectively, in the ≤2 cm group and 97.4%, 100%, and 97.4%, respectively, in the >2 cm group, with no significant differences between the groups. There was no difference in adverse events between the groups (0% in the ≤2 cm group and 2.3% in the >2 cm group). Conclusions: EUS-TA for small focal liver lesions measuring ≤2 cm has favorable outcomes, which are similar to those for lesions measuring >2 cm.

A novel puzzle ring replacement technique of a lumen-apposing metal stent with a double-pigtail plastic stent to prevent walled-off necrosis recurrence (with video).

Replacing a lumen-apposing metal stent (LAMS) with a double-pigtail plastic stent (DPS) after treatment for walled-off necrosis contributes to the prevention of recurrence. However, the success rate is not very high. To overcome this issue, we devised a novel stent-replacement technique. In the final treatment procedure, a 7-F DPS was placed in the lumen of the LAMS. Subsequently, the walled-off necrosis shrank, and granulation formed over the pigtail portion, which fixed the DPS. The LAMS alone was removed with grasping forceps, leaving the DPS in the lumen of the LAMS (i.e., a puzzle-ring technique; direct or rotary removal technique). Between August 2021 and August 2023, 18 patients were evaluated for recurrence prevention using this novel technique (median duration of LAMS placement, 37 days). In 17 patients (94.4%), the LAMS was successfully replaced with a 7-F DPS (direct technique 14, rotary technique 3; median removal procedure time, 3 min). No recurrence was observed during the median observation period of 385 days. Before using this technique (April 2012 to August 2022), the technical success rate of replacement of LAMS with 7-F DPS was significantly lower (61.8% [42/68, p = 0.02]). Recurrence of pancreatic fluid collection occurred in 15.3% (4/26) of the patients who could not undergo replacement with a 7-F DPS. The novel puzzle ring technique, which improves the success rate of LAMS for DPS replacement, may be useful in reducing recurrence after walled-off necrosis treatment.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in patients with a history of multiple primary malignant neoplasms.

Objective: This study aimed to investigate the usefulness of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing focal liver lesions in patients with a history of multiple primary malignant neoplasms. Methods: Among patients who underwent EUS-TA for focal liver lesions between 2016 and 2022, those with a history of multiple malignant neoplasms were included. A histologically confirmed malignant tumor within the past 5 years before EUS-TA was defined as a history of malignant neoplasm. The primary outcomes were diagnostic ability and adverse events of EUS-TA. Results: This study included 16 patients (median age, 73 [33-90] years), the median tumor size was 32 (6-51) mm, 14 had a history of double malignant neoplasms, whereas two had triple malignant neoplasms. Malignant neoplasms were detected histologically or cytologically in all cases. Immunohistochemistry was performed in 75% (12/16), and the final diagnosis of EUS-TA was metastatic liver tumor in 12 patients, and primary malignant liver tumor in four patients. The primary site could be identified in 11 of 12 metastatic tumor cases. The diagnostic yield of EUS-TA was 100% (16/16) for differentiating benign and malignant tumors and 94% (15/16) for confirming the histological type including the primary site of metastatic lesions. No adverse events were associated with the procedure. Conclusion: EUS-TA is a useful diagnostic modality for focal liver lesions in patients with a history of multiple malignant neoplasms, allowing for the differential diagnosis of primary and metastatic tumors and identification of the primary site of metastatic lesions.

A case of intra-abdominal gossypiboma diagnosed preoperatively by endoscopic ultrasound fine-needle-aspiration.

Gossypiboma is an extremely rare adverse event occurring post-surgery, where surgical gauze is left within the body. If aseptically retained, it can lead to the formation of granulation tissue through chronic inflammation and adhesion with surrounding tissues, potentially persisting asymptomatically for many years. While diagnosis of this condition has been reported through various imaging modalities such as abdominal ultrasound and computed tomography, cases not presenting with typical findings are difficult for preoperative diagnosis, and instances where it is discovered postoperatively exist. Particularly when in contact with the gastrointestinal tract within the abdominal cavity, differentiation from submucosal tumors of the digestive tract becomes problematic. This report describes the imaging characteristics of endoscopic ultrasound and the usefulness of endoscopic ultrasound-fine-needle-aspiration for tissue diagnosis in the preoperative diagnosis of intra-abdominal gossypiboma.

Advances in Pediatric Endoscopy.

Diagnostic and therapeutic endoscopic procedures in children are fundamental to the subspecialty of pediatric gastroenterology. This review highlights significant advancements and trends in pediatric endoscopy, emphasizing the transformative impact of technological innovations in the field. The advent of ultra-thin endoscopes and the development of minimally-invasive techniques have markedly enhanced both diagnostic and therapeutic capabilities, leading to safer and more effective procedures for pediatric patients. Key advancements include transnasal endoscopy, endoscopic ultrasound, and per-oral endoscopic myotomy.

Diagnostic Endoscopic Ultrasound.

The last two decades have seen the emergence of endoscopic technologies and techniques allowing for minimally invasive modalities for assessing and sampling lesions inside and outside of the gastrointestinal lumen, including the chest, abdomen, and pelvis. Incorporating these new endoscopic approaches has revolutionized the diagnosis and staging of intraluminal and extraluminal lesions and enabled more accessible and safer tissue acquisition.

Therapeutic Endoscopic Ultrasound and Endoscopic Ultrasound-Endoscopic Retrograde Cholangiopancreatography Interventions.

Therapeutic endoscopic ultrasound (EUS) encompasses an array of procedures to manage pancreaticobiliary and luminal gastrointestinal disorders. Therapeutic EUS procedures include EUS-guided rendezvous of the pancreatic and biliary ducts, as well as direct drainage of the bile duct, pancreatic duct, and gallbladder, drainage of pancreatic fluid collections, and luminal anastomosis creation. These procedures have a range of required equipment, approaches, clinical outcomes, and adverse events dependent on both procedure-related and patient-related factors. In expert hands, these procedures provide patients with less invasive options and can achieve excellent clinical outcomes.

Endo-hepatology: Why should we do endoscopic ultrasound-guided interventions to the liver that we could do through the skin?

Endoscopic ultrasound (EUS)-guided interventions on the liver such as diffuse biopsy and portal pressure gradient measurement are emerging as potential alternatives to percutaneous procedures. The purpose of this editorial was to address all the indications that could potentially make an EUS-guided approach a possible alternative to the percutaneous procedures with respect to the proce-dures that could join the EUS examination such as upper endoscopy for gastro-esophageal varices, pancreaticobiliary investigation with EUS, and other potential advantages in terms of patient safety. The issue of a holistic gastroenterologist approach was also discussed along with the potential for developing clinical research.

Effectiveness of endoscopic ultrasound-guided simple puncture-aspiration (non-stenting) in the management of abdominal collections.

Background: Endoscopic management of abdominal collections includes endoscopic ultrasound (EUS)-guided transmural drainage, transpapillar via endoscopic retrograde cholangiopancreatography (ERCP), and EUS-guided simple puncture-aspiration (SPA). The latter is little reported, and there are some doubts about its real usefulness. Objectives: The aim of this study was to assess the effectiveness of EUS-guided SPA as a first-line approach for treatment in selected abdominal collections. Design: Retrospective observational study performed in two tertiary centers (Barcelona area). Methods: Inclusion of all consecutive patients with abdominal collections that underwent EUS-guided SPA from July 2007 to July 2021. The decision was based on endoscopist criteria and collection characteristics. Clinical success was defined as avoidance of an additional interventional approach (endoscopic stenting, percutaneous drainage, surgery). Results: Of 241 patients with abdominal collections treated endoscopically, 55 were included for analysis (mean age, 56 ± 12 years). Collection features: mean size 63.3 ± 24.8 mm; positive culture in 22 (40%) and pancreatic nature in 45 (81.8%). EUS-SPA was performed successfully in all cases, and clinical success was achieved in 76.3% (95% confidence interval (CI), 65.5-87.3) of cases (n-42/55). The most frequently used needle size was 19 Ga (85%). A nonsignificant trend for success was detected for noninfected collections (84.8 vs 63.6; p = 0.07) and lower size (mean ± SD; 60.2 ± 22.9 vs 73.8 ± 29 mm; p = 0.09). Two related adverse events were detected: one bleeding and one abdominal pain. Recurrence was detected in five pseudocysts after clinical success. Median follow-up was 629 days (IQR 389-877). Conclusion: EUS-SPA of selected abdominal collections seems to be a safe and effective technique, avoiding a more aggressive strategy such as transmural stenting. EUS-SPA may be a viable alternative in collections with limited size and preferably noninfected.

Evaluation of Deep Remission with Through-The-Scope Catheter-Based Endoscopic Ultrasound during Double Balloon Enteroscopy in Small Bowel Crohn's Disease.

BACKGROUND AND AIMS: Evaluation of deep remission in Crohn's disease (CD) can be challenging when the disease is confined to the small intestine. The aim of this study was to evaluate the effectiveness of through-the-scope (TTS) endoscopic ultrasound (EUS) during Double-balloon enteroscopy (DBE) in distinguishing small-bowel CD patients in endoscopic remission from those with active disease. METHODS: Patients who underwent DBE-EUS were divided into groups of endoscopic remission and endoscopic activity according to segmental Simple Endoscopic Score for Crohn's Disease (SES-CD). Thickness of small intestinal wall layers and other parameters were evaluated by EUS. RESULTS: EUS using the ultrasonic catheter probe via DBE showed that the total wall thickness (TWT) and submucosal thickness (SMT) of the small intestine in the active group were significantly greater than those in the remission group (TWT 3.84±1.02 vs 2.42±0.25mm, SMT 1.23±0.34 vs 0.79±0.13mm, respectively, p<0.001). Cut-off values of 2.65 mm for TWT and 0.95 mm for SMT can distinguish active small-bowel CD from inactive disease (Sensitivity 91.5%, Specificity 80.8% and Sensitivity 70.2%, Specificity 88.6%, respectively). The correlation analysis revealed a significant positive correlation between TWT and SES-CD (r=0.930, p<0.001). Furthermore, TWT was strongly correlated with FC (r=0.861, p<0.001) and CDAI (r=0.805, p<0.001). Similar results were observed for SMT. CONCLUSIONS: EUS using an ultrasonic catheter probe during DBE is effective in evaluation of both mucosal and transmural healing in small-bowel CD patients. DBE-EUS could become an important tool in the management of patients with small-bowel CD.

Endoscopic Ultrasound Guided Gastro-enterostomy for Malignant Gastric Outlet Obstruction: Impact of Clinical and Demographic Factors on Outcomes.

BACKGROUND AND AIMS: Endoscopic ultrasound guided gastroenterostomy (EUS-GE) has emerged as an alternative to surgical gastrojejunostomy and endoluminal stenting for malignant gastric outlet obstruction (MGOO). Studies regarding factors associated with the EUS-GE outcomes are limited. METHODS: A retrospective observational study was conducted with consecutive patients who underwent EUS-GE for MGOO at our center from January 2016 to November 2023. Primary outcomes were technical success (Establishing EUS-GE) and clinical success (Low residue diet tolerance without re-intervention at 90-day follow-up). Secondary outcomes were adverse events (AEs), reinterventions and full regular diet tolerance. RESULTS: Technical success and clinical success rates were 92.70% (127/137) and 88.00%, respectively, with 42.86% of the patients tolerating a regular diet. Patients with peritoneal carcinomatosis had lower odds of technical success (OR: 0.19, 95% CI: 0.04-0.93). Obstruction at the level of stomach, compared to duodenum, had lower odds of clinical success (OR: 0.06, 95% CI: 0.006-0.56). AE and reintervention rates were 14.17% and 8.66%, respectively. NGT decompression prior to EUS-GE was associated with lower AE rates in multivariable analysis (OR: 0.32, 95% CI: 0.11-0.95). Prior gastrointestinal surgery was associated with reintervention in multivariable analysis (OR: 4.09; 95% CI: 1.02-16.45, p-value: 0.047). CONCLUSION: EUS-GE has high technical and clinical success rates, with many patients tolerating regular diet. Routine NGT decompression should be considered to minimize AEs. MGOO at the level of stomach is associated with lower clinical success rates. Extra care should be taken while performing EUS-GE in patients with peritoneal carcinomatosis. Prior gastrointestinal surgery is a likely risk factor for reintervention.

Advanced ultrasound diagnosis of extrahepatic bile duct lesions.

Ultrasound (US) has high specificity and sensitivity, and it should be performed first for patients with suspicion of biliary tract cancer. However, the complicated anatomy in addition to the gas images makes it difficult to delineate the entire extrahepatic bile duct (EHBD). The keys to depiction of EHBD are the "J" shape manipulation in the left lateral decubitus position and the use of magnified images with high-frequency transducers. Furthermore, indirect findings such as gallbladder (GB) distension, BD dilatation, and debris echo in the GB and BD are also important for detecting occult lesions, particularly in the ampullary region of Vater. For the differential diagnosis of BD wall thickening, the spreading pattern in the long and short axial directions should be assessed first. Then, the characteristics of the innermost hyperechoic layer (IHL) and outermost hyperechoic layer (OHL) should be evaluated. Asymmetrical wall thickening, absence of IHL, and presence of irregularity or discontinuity in OHL are characteristic patterns of cholangiocarcinoma (CCA). Because CCA is the most common BD polypoid lesion, it is important to diagnose tumor extension and depth invasion in addition to differential diagnosis. Nodular-type CCA is usually hypoechoic and more likely to invade vertically. In contrast, papillary-type CCA is often hyperechoic and extends laterally. Contrast­enhanced US may be useful for evaluating these findings. However, if the possibility of CCA cannot be ruled out or a definitive diagnosis is needed, a transpapillary biopsy or endoscopic US-guided tissue acquisition should be considered.

A convolutional neural network-based system for identifying neuroendocrine neoplasm and multiple types of lesions in the pancreas via endoscopic ultrasound (with videos).

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS) is sensitive in detecting pancreatic neuroendocrine neoplasm (pNEN). However, the endoscopic diagnosis of pNEN is operator-dependent and time-consuming since pNEN mimics normal pancreas and other pancreatic lesions. We intended to develop a convolutional neural network (CNN)-based system named iEUS for identifying pNEN and multiple types of pancreatic lesions via EUS. METHODS: Retrospective data of 12,200 EUS images obtained from pNEN and non-pNEN pancreatic lesions, including pancreatic ductal adenocarcinoma (PDAC), autoimmune pancreatitis (AIP), and pancreatic cystic neoplasm (PCN), were used to develop iEUS. It was composed of a two-category (pNEN/ non-pNEN pancreatic lesion) classification model (CNN1) and a four-category (pNEN/ PDAC/ AIP/ PCN) classification model (CNN2). Videos from consecutive patients were prospectively collected for a human-iEUS contest to evaluate the performance of iEUS. RESULTS: A total of 573 patients were enrolled in this study. In the human-iEUS contest containing 203 videos, CNN1 and CNN2 showed an accuracy of 84.2% and 88.2% for diagnosing pNEN, respectively, which were significantly higher than that of novices (75.4%) and comparable with intermediate endosonographers (85.5%) and experts (85.5%). In addition, CNN2 showed an accuracy of 86.2%, 97.0%, and 97.0% for diagnosing PDAC, AIP, and PCN, respectively. With the assistance of iEUS, the sensitivity of endosonographers at all three levels in diagnosing pNEN has significantly improved (64.6% vs. 44.8%, 87.5% vs. 71.9%, 74.0% vs. 57.6%, respectively). CONCLUSIONS: The iEUS precisely diagnosed pNEN and other confusing pancreatic lesions, thus could assist endosonographers in achieving more accessible and accurate endoscopic diagnoses via EUS.

Diagnostic ability and adverse events of mucosal incision-assisted biopsy for gastric subepithelial tumors: Systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis aimed to evaluate the diagnostic ability and examine the efficacy of countermeasures to adverse events of mucosal incision-assisted biopsy (MIAB) for gastric subepithelial tumors (SETs). METHODS: We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary end-point was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary end-point was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined. RESULTS: Nine studies were conducted in Japan and two in South Korea, of which only two were prospective studies. The pooled pathological diagnostic rate of MIAB for gastric SETs was 87.8% (95% confidence interval [CI] 80.2-94.0; I2 = 68.7%). The adverse event rate of the pooled population was 0.2% (95% CI 0-1.4; I2 = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio 0.06, 95% CI 0.01-0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local and nonlocal injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively. CONCLUSIONS: MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors may effectively prevent postoperative bleeding; however, the efficacy of local injection remains unclear. This technique could be an option for tissue sampling in gastric SETs.

Evaluation of Needles in Endoscopic Ultrasound-Guided Tissue Acquisition of Pancreatic Cancer for Genetic Yield and Quality.

BACKGROUND: Endoscopic ultrasound-guided fine needle biopsy (FNB) is the gold standard in tissue acquisition of pancreatic ductal adenocarcinoma (PDAC). There is a paucity of evidence of the impact of needle type or size on the genetic yield and quality. METHODS: Patients 18 years and older with PDAC who underwent FNB were retrospectively identified from a single database from 2016 to 2021. Genetic quantity is measured in micrograms (µg) and quality defined by RNA or DNA integrity number (RIN and DIN). FNB needles examined were Acquire 22 gauge (Boston Scientific, Marlborough, MA, USA) and ProCore 22 and 20 gauges (Cook Medical, Bloomington, IN, USA). RESULTS: Two hundred seventy-seven patients were identified. ProCore 20G needle procured higher RNA quantity (4125.8µg, IQR: 2003.8, 5954.8, p = 0.012) compared to ProCore 22G (2050µg IQR: 966.4, 3181.6) and Acquire 22G (2310.6µg, IQR: 1439.3, 4312). Median DNA quantity was 3340.5µg (Acquire 22G), 2610.4µg (ProCore 22G) and 3499.7µg (ProCore 20G) (p = 0.763). Median DIN was 7.3 (Acquire 22G and ProCore 22G) and 7.4 (ProCore 20G) (p = 0.449). Median RIN was 3.0 (Acquire 22G and ProCore 22G) and 2.7 (ProCore 20G) (p = 0.886). CONCLUSION: ProCore 20G was associated with higher quantity of RNA. There were no differences in the quality acquired by different needles.

Portuguese Pancreatic Club Perspective on the Surveillance Strategy for Pancreatic Neuroendocrine Tumours: When and How to Do It?

Background: Pancreatic neuroendocrine tumours (pNETs) are a highly heterogeneous group of tumours with widely variable biological behaviour. The incidence of pNETs has risen exponentially over the last three decades, particularly for asymptomatic small pNETs (≤2 cm), due to the widespread use of cross-sectional imaging in clinical practice. Summary: Current consensus guidelines suggest that incidentally discovered pNETs ≤2 cm can be selectively followed due to the overall low risk of malignancy. Nevertheless, the "watch-and-wait" management strategy for small asymptomatic pNETs is still not widely accepted due to the lack of long-term data on the natural history of these small lesions. Additionally, it is clear that a subset of small pNETs may show malignant behaviour. Key Message: Given the non-negligible risk of malignancy even in small pNETs, it is of the utmost importance to identify other preoperative factors, other than size, that may help to stratify the risk of malignant behaviour and guide clinical management. In this article, the Portuguese Pancreatic Club reviews the importance of risk stratification of pNETs and presents an updated perspective on the surveillance strategy for sporadic well-differentiated pNETs.

Contexto: Os tumores neuroendócrinos do pâncreas (pNETs) correspondem a um grupo heterogéneo de tumores com comportamento biológico variável. A sua incidência aumentou exponencialmente nas últimas três décadas, particularmente à custa do diagnóstico incidental de pNETs de reduzidas dimensões (≤2 cm) devido à utilização crescente de exames de imagem seccional na prática clínica. Sumário: As normas de consenso internacionais sugerem que os pNETs ≤2 cm poderão ser seletivamente vigiados, dado o seu baixo risco global de comportamento maligno. No entanto, a estratégia proposta de "watch and wait" na abordagem dos pNETs assintomáticos ≤2cm não tem sido amplamente aceite devido à ausência de dados a longo-prazo relativos à sua história natural. Adicionalmente, é hoje evidente que um subgrupo destes pequenos tumores poderá apresentar comportamento maligno. Mensagens Chave: Dado o risco não desprezível de agressividade biológica mesmo nos pNETs incidentais de reduzidas dimensões, torna-se essencial identificar fatores pré-operatórios, para além da dimensão do tumor, que permitam estratificar o seu risco de malignidade e guiar a abordagem clínica. No presente artigo o Clube Português de Pâncreas apresenta uma perspectiva atual sobre a estratificação do risco e a estratégia a adoptar na vigilância dos pNETs esporádicos bem-diferenciados.

Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) for Pancreatic Adenocarcinoma: A Review.

Pancreatic ductal adenocarcinoma (PDAC) is still one of the deadliest neoplasms in the world. Although various advancements in the treatment and management of this disease have been made, no significant overall survival benefit has been achieved. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been proposed as a treatment for patients who are unfit for surgery or with inoperable PDAC. We conducted a literature review of the PubMed and Embase databases to identify and analyze studies on the use of EUS-RFA in inoperable PDAC. Eleven studies with a total of 122 patients were analyzed to assess the population characteristics, feasibility and safety of the procedure, and overall survival of the population. Technical success was achieved in 95.1% of cases, and no intraoperative complications were reported. The most common early complication reported was abdominal pain (21 out of 122 patients) with a total early complication rate of 29.6%, and none of these complications affected hospital stays or post-procedure recovery. Late complications were reported in four patients (3.2%). Post-procedure cytoreduction was achieved in all patients, although disease progression was reported in 119 of 122 patients. The overall survival rate did not differ from that reported in the literature. We found that EUS-RFA could be a valid palliative option for inoperable patients, a bridge for surgery reducing the size of the tumor and its vascular relationship, or a first-line therapy in a subset of selected patients. Larger cohort and prospective studies should be conducted to establish guidelines for this procedure.

Linear endoscopic ultrasound: Current uses and future perspectives in mediastinal examination.

This editorial elaborates on the current and future applications of linear endoscopic ultrasound (EUS), a substantial diagnostic and therapeutic modality for various anatomical regions. The scope of endosonographic assessment is broad and, among other factors, allows for the evaluation of the mediastinal anatomy and related pathologies, such as mediastinal lymphadenopathy and the staging of central malignant lung lesions. Moreover, EUS assessment has proven more accurate in detecting small lesions missed by standard imaging examinations, such as computed tomography or magnetic resonance imaging. We focus on its current uses in the mediastinum, including lung and esophageal cancer staging, as well as evaluating mediastinal lymphadenopathy and submucosal lesions. The editorial also explores future perspectives of EUS in mediastinal examination, including ultrasound-guided therapies, artificial intelligence integration, advancements in mediastinal modalities, and improved diagnostic approaches for various mediastinal lesions.