Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis.

BACKGROUND AND AIMS: EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied. METHODS: We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis. RESULTS: LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses. CONCLUSIONS: For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

(#WomeninDDW) Persistent Speaker Gender Gap at the Premier Digestive Disease Event.

BACKGROUND: Over the last few decades, advances have been made regarding gender equality starting from medical students to trainees, to leadership in academics. The female representation in specialty academic conferences not only reflects the existing gender disparities in that specialty but also can influence young female trainees to join that field. Digestive Disease Week (DDW) is the premier digestive disease event. We aimed to calculate the proportion of female representation among speakers and moderators at the DDW meetings held from 2018 to 2020. METHODS: The data for DDW 2018-2020 were collected via the online web-based planner. The gender of speakers of presentations and moderators of sessions were identified by a google search. We further categorized the data by each participating society (AGA, ASGE, AASLD, and SSAT), by presentation track, by session track, and total overall representation in each year. RESULTS: Despite the subject of the gender gap being in focus, the proportion of female moderators and speakers was low in DDW in the last 3 years. The female speakers constituted 31.6% in 2018, 33.8% in 2019 and 34.6% in 2020. There was slightly improved female representation in sessions of Inflammatory Bowel Disease, Stomach, and Small Bowel Disorders, Microbiome in GI & Liver disease, and Basic Science over the last 3 years. CONCLUSION: Based on our study and those referenced in this article, we believe that strategies to promote the inclusivity of female moderators and speakers at DDW provide a huge opportunity to influence gender equity within GI.

Bleeding Risk and Mortality Associated With Uninterrupted Antithrombotic Therapy During Percutaneous Endoscopic Gastrostomy Tube Placement.

INTRODUCTION: Antithrombotic therapy is often interrupted before the placement of a percutaneous endoscopic gastrostomy (PEG) tube because of potentially increased risk of hemorrhagic events. The aim of our study was to evaluate the risk of bleeding events and overall complication rates after PEG in patients on uninterrupted antiplatelet and anticoagulation therapy in a high-volume center. METHODS: Data regarding demographics, diagnoses, comorbidities, and clinical outcomes pertinent to PEG were collected from 2010 to 2016. Furthermore, data regarding antithrombotic therapy along with the rate of minor or major complications including bleeding associated with this procedure were analyzed. Significant bleeding was defined as postprocedure bleeding from PEG site requiring a blood transfusion and/or surgical/endoscopic intervention. RESULTS: We included 1,613 consecutive PEG procedures in this study, of which 1,540 patients (95.5%) received some form of uninterrupted antithrombotic therapy. Of those patients, 535 (34.7%) were on aspirin, 256 (16.6%) on clopidogrel, and 119 (7.7%) on both aspirin and clopidogrel. Subcutaneous heparin was uninterrupted in 980 (63.6%), intravenous heparin in 34 (2.1%), warfarin in 168 (10.9%), and direct-acting oral anticoagulation in 82 (5.3%) patients who overlapped on multiple drugs. We observed 6 significant bleeding events in the entire cohort (0.39%), and all were in subcutaneous heparin groups either alone or in combination with aspirin. No clinically significant bleeding was noted in patients on uninterrupted aspirin, warfarin, clopidogrel, or direct-acting oral anticoagulation groups. Only 5 patients (0.31%) had PEG-related mortality. DISCUSSION: The risk of significant bleeding associated with the PEG placement was minimal in patients on uninterrupted periprocedural antithrombotic therapy.

Comparing diagnostic accuracy of current practice guidelines in predicting choledocholithiasis: outcomes from a large healthcare system comprising both academic and community settings.

BACKGROUND AND AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) 2010 guidelines for suspected choledocholithiasis were recently updated by proposing more specific criteria for selection of high-risk patients to undergo direct ERCP while advocating the use of additional imaging studies for intermediate- and low-risk individuals. We aim to compare the performance and diagnostic accuracy of 2019 versus 2010 ASGE criteria for suspected choledocholithiasis. METHODS: We performed a retrospective chart review of a prospectively maintained database (2013-2019) of over 10,000 ERCPs performed by 70 gastroenterologists in our 14-hospital system. We randomly selected 744 ERCPs in which the primary indication was suspected choledocholithiasis. Patients with a history of cholecystectomy or prior sphincterotomy were excluded. The same patient cohort was assigned as low, intermediate, or high risk according to the 2010 and 2019 guideline criteria. Overall accuracy of both guidelines was compared against the presence of stones and/or sludge on ERCP. RESULTS: Of 744 patients who underwent ERCP, 544 patients (73.1%) had definite stones during ERCP and 696 patients (93.5%) had stones and/or sludge during ERCP. When classified according to the 2019 guidelines, fewer patients were high risk (274/744, 36.8%) compared with 2010 guidelines (449/744, 60.4%; P < .001). Within the high-risk group per both guidelines, definitive stone was found during ERCP more frequently in the 2019 guideline cohort (226/274, 82.5%) compared with the 2010 guideline cohort (342/449, 76.2%; P < .001). In our patient cohort, overall specificity of the 2010 guideline was 46.5%, which improved to 76.0% as per 2019 guideline criteria (P < .001). However, no significant change was noted for either positive predictive value or negative predictive value between 2019 and 2010 guidelines. CONCLUSIONS: The 2019 ASGE guidelines are more specific for detection of choledocholithiasis during ERCP when compared with the 2010 guidelines. However, a large number of patients are categorized as intermediate risk per 2019 guidelines and will require an additional confirmatory imaging study.

Endoscopic Gastrointestinal Anastomosis Using Lumen-apposing Metal Stent (LAMS) for Benign or Malignant Etiologies: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIM: Endoscopic gastrointestinal anastomosis using lumen-apposing metal stents (EGAL) is a new technique that is used as an alternative method to bypass benign or malignant strictures. Endoscopists take advantage of 2 bowel loops that are close to each other and place a stent between the lumen of these 2 bowel loops. The authors performed this systematic review and meta-analysis to evaluate the efficacy and safety of this rising procedure. METHODS: Electronic database searches were conducted for full eligible articles that were published from the inception to July 2019 using the EGAL procedure to bypass malignant or benign obstruction or to restore bowel integrity after a gastrointestinal altering surgery. The primary outcome of this meta-analysis was to assess efficacy through technical and clinical success. Secondary outcomes were to assess safety through adverse events and to assess the rate of stent maldeployment and the rate of reintervention during the study period. RESULTS: Eight studies were eligible, providing data on 269 patients who underwent 271 EGAL procedures. The median age was 65 years (interquartile range: 63 to 66) with 46% male individuals. Out of 269 patients, 203 underwent EGALs because of malignant etiology and 66 underwent EGAL for benign etiology. The median duration of follow-up was 114 days (interquartile range: 78 to 121). Technical success rate was 94.1% [95% confidence interval (CI), 91.4%-96.9%]. Clinical success rate was 91.4% (95% CI, 88.1%-94.7%). Adverse events rate was 8.5% (95% CI, 4.7%-12.3%). Stent maldeployment rate was 9.5% (95% CI, 3.5%-15.4%) of the total performed EGALs and the reintervention rate was 6.0% (95% CI, 2.3%-9.8%). CONCLUSION: EGAL procedure has high efficacy and a relatively safe profile and it can be performed in selected patients. Comparison between EGAL and other conventional therapies is difficult because of the lack of randomized trials.

Endoscopic ultrasound-guided parenchymal liver biopsy: a systematic review and meta-analysis.

BACKGROUND: Endoscopic ultrasonography (EUS)-guided liver biopsy is a novel technique to obtain adequate liver samples for diagnosis of liver parenchymal diseases. There are studies that have evaluated the feasibility and safety of EUS-guided parenchymal liver biopsy (EUS-LB), however, factors that can influence specimen quality are yet to be determined. Our aim was to determine the diagnostic accuracy of EUS-LB and evaluate factors associated with specimen quality. METHODS: We performed a detailed search of PubMed/MEDLINE and Web of Science™ databases to identify studies in which results of EUS-guided liver parenchymal biopsies were reported published up to July 2020. A random effects model was used to estimate pooled values (mean ± SE) for total specimen length (TSL) and complete portal tracts (CPT). Subgroup analyses were applied to find out the procedural factors associated with better specimen quality using Cochran's Q test. A total of 10 meta-analyses were done focusing on international studies. Total of 1326 patients who underwent EUS-LB. EUS-LBs performed for suspicion of parenchymal liver disease. Pooled mean values for TSL and CPT with subgroup analyses. RESULTS: Twenty-three studies with a total of 1326 patients were included in our meta-analysis. Overall pooled mean TSL and CPT were 45.3 ± 4.6 mm and 15.8 ± 1.5, respectively. In subgroup analysis, core biopsy needles proved to better in terms of CPT than fine-needle aspiration needles (18.4 vs 10.99, p = 0.003). FNB with slow-pull or suction technique provided a similar TSL (44.3 vs 53.9 mm, p = 0.40), however, slow-pull technique was better in terms of CPT (30 vs 14.6, p < 0.001). Heterogeneity was present among the studies. Another limitation is the low number randomized control trials. CONCLUSION: EUS-guided parenchymal liver biopsy is a good alternative to other methods of liver sampling. Using FNB needles with a slow-pull technique can provide better results.

Safety of endoscopic interventions in patients with thrombocytopenia.

BACKGROUND: The risk of endoscopic interventions in thrombocytopenia has received little attention in the medical literature. OBJECTIVE: The aim of this study was to assess the safety of endoscopic interventions including evaluation of GI bleeding (GIB) in patients with thrombocytopenia. DESIGN AND SETTING: Retrospective study, tertiary oncology center. PATIENTS AND INTERVENTION: Review of consecutive endoscopies with preprocedure platelet counts (PCs) of 75 × 10(3)/µL or lower. MAIN OUTCOME MEASUREMENTS: Risk of bleeding with routine endoscopic interventions and transfusion requirement after evaluation of GIB. RESULTS: A total of 617 (351 upper, 266 lower [90 colonoscopies]) endoscopies were performed in 395 patients. Forceps-biopsy specimens were obtained in 398 endoscopies (mean ± standard deviation [SD] PC: 38.21 ± 11.7 × 10(3)/µL) and 45 polypectomies were performed in 17 endoscopies (mean ± SD PC: 39.65 ± 8.53 × 10(3)/µL). The risk of bleeding was 1.5% (6 of 398 endoscopies) at the biopsy site and 4% (2 of 45 polypectomies) at the polypectomy site. Active GIB (mean ± SD PC: 32.85 ± 4.0 × 10(3)/µL) was observed in 68 (11% of 617) endoscopies and intervention (mean ± SD PC: 33.68 ± 4.6 × 10(3)/µL) was performed in 41 procedures. Together, angiodysplasias and ulcers were the most common etiology (51.2% of 41). Hemostasis was achieved in 39 (95.1% of 41) procedures. Comparison of blood transfusions ± 3 days of successful therapy showed a 52% reduction (P < .001). By multivariate analysis, a higher aggregate blood transfusion 3 days preceding endoscopy (odds ratio 1.32; 95% confidence interval, 1.16-1.50; P < .001) predicted endoscopic findings of active GIB. LIMITATIONS: Retrospective design, single center. CONCLUSIONS: In the largest endoscopic experience reported in thrombocytopenic patients (Common Terminology Criteria for Adverse Events grade 3 or lower), bleeding caused by standard forceps biopsy and polypectomy (≤10 mm) was minor and easily controlled. Endoscopic therapy for GIB is safe and significantly reduces the packed red blood cell requirement and should be considered in patients with thrombocytopenia in the setting of an appropriate transfusion strategy.

Safety and Efficacy of Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy of Littoral Cell Angioma.

Littoral cell angioma (LCA) is a rare vascular tumor of the spleen that often requires histopathological analysis for diagnosis due to non-specific imaging features. The current approach is either splenectomy or image-guided percutaneous biopsy which carries notable procedure-associated morbidity and limited accuracy. We present a novel case of LCA successfully diagnosed with endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB), demonstrating its potential to reduce the morbidity associated with traditional percutaneous biopsy methods. This case highlights EUS-FNAB's advantage in minimizing complications and its effectiveness in diagnosing vascular tumors of the spleen, supporting its inclusion in the diagnostic algorithm for splenic lesions. Further cases are encouraged to explore EUS-FNAB's role in diagnosing rare vascular tumors such as LCA to establish its efficacy and safety profile.

Comparison of the utility of covered metal stents versus uncovered metal stents in the management of malignant biliary strictures in 749 patients.

BACKGROUND: Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstruction. OBJECTIVE: To compare outcomes between covered self-expandable metal stents (CSEMSs) and uncovered self-expandable metal stents (USEMSs) in malignant biliary obstruction. DESIGN: Retrospective cohort study. SETTING: Tertiary cancer center. PATIENTS: Patients with malignant biliary obstruction. INTERVENTIONS: Placement of CSEMS or USEMS. MAIN OUTCOME MEASUREMENTS: Time to recurrent biliary obstruction (TRO), overall survival (OS), and adverse events. RESULTS: From January 2000 to June 2011, 749 patients received SEMSs: 171 CSEMSs and 578 USEMSs. At 1 year, there was no significant difference in the percentage of patients with recurrent obstruction (CSEMSs, 35% vs USEMSs, 38%) and survival (CSEMSs, 45% vs USEMSs, 49%). There was no significant difference in the median OS (CSEMSs, 10.4 months vs USEMSs, 11.8 months; P = .84) and the median TRO (CSEMSs, 15.4 months vs USEMSs, 26.3 months; P = .61). The adverse event rate was 27.5% for the CSEMS group and 27.7% for the USEMS group. Although tumor ingrowth with recurrent obstruction was more common in the USEMS group (76% vs 9%, P < .001), stent migration (36% vs 2%, P < .001) and acute pancreatitis (6% vs 1%, P < .001) were more common in the CSEMS group. LIMITATIONS: Retrospective study. CONCLUSIONS: There was no significant difference in the patency rate or overall survival between CSEMSs and USEMSs for malignant distal biliary strictures. The CSEMS group had a significantly higher rate of migration and pancreatitis than the USEMS group. No significant SEMS-related adverse events were observed in patients undergoing neoadjuvant chemoradiation or surgical resection.

Rapunzel Syndrome Complicated by Escherichia coli Sepsis, Bowel Perforation, and Pancreatitis in an 11-year-old Malnourished Female.

The most common presenting symptoms of Rapunzel syndrome include abdominal pain (37%), nausea and vomiting (33.3%), obstruction (25.9%), and peritonitis (18.3%). Less commonly, patients may present with weight loss (7.4%) or intussusception (7.4%). Exceedingly rare complications of Rapunzel syndrome include gastric ulceration, obstructive jaundice, and acute pancreatitis as well as other malabsorptive-related complications including protein-losing enteropathy, iron deficiency, and megaloblastic anemia. This report details the case of an 11-year-old female with Rapunzel syndrome complicated by sepsis, a rare complication reported in only 2% of patients.

Practice patterns and adherence to society guidelines for suspected choledocholithiasis: A comparison of academic and community settings from a large US healthcare system.

Background: The American Society of Gastrointestinal Endoscopy (ASGE) has proposed practice guidelines for evaluating patients with suspected choledocholithiasis. This study aims to assess and compare practice patterns for following ASGE guidelines for choledocholithiasis in a large academic vs. community hospital setting. Methods: A total of one thousand ER indicated for choledocholithiasis were randomly selected. Patients' demographics, total bilirubin, imaging studies including magnetic resonance cholangiopancreatography (MRCP), intraoperative cholangiogram (IOC), endoscopic ultrasound (EUS), and ERCP results were retrospectively collected. Patients with prior sphincterotomy were excluded. We examined the following practice deviations from the current ASGE guidelines; (1) ERCP was potentially delayed in high probability cases while awaiting additional imaging studies, (2) ERCP was performed without additional imaging studies in cases of low/intermediate-risk, or (3) ERCP was performed in low/intermediate-risk cases when additional imaging studies were negative. Results: A total of 640 patients with native papilla who underwent ERCP were included in the final analysis. Overall, the management of 43% (275) of patients was deviated from the applicable ASGE guidelines. Academic and community provider rates of non-adherence were 32 vs. 45%, respectively (p-value: < 0.01). Of 381 high-risk cases, 54.1% had additional imaging before ERCP. (Academic vs. community; 11.7 vs. 88.3%, p-value: < 0.01). In 26.7% (69/258) of low/intermediate risk cases, ERCP was performed without additional studies; academic (14.5%) vs. community (85.5%) (p-value: < 0.01). Finally, in 11.2% (19/170) of patients, ERCP was performed despite intermediate/low probability and negative imaging; academic (26.3%) vs. community (73.7%) (p-value: 0.02). Conclusion: Our study results show that providers do not adhere to ASGE practice guidelines in 43% of suspected choledocholithiasis cases. The rate of non-adherence was significantly higher in community settings. It could be due to various reasons, including lack/delays for alternate studies (i.e., MRCP, EUS), concern regarding the length of stay, patient preference, or lack of awareness/understanding of the guidelines. Increased availability of alternate imaging and educational strategies may be needed to increase the adoption of practice guidelines across academic and community settings to improve patient outcomes and save healthcare dollars.

Is antibiotic prophylaxis necessary after endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts?

BACKGROUND/AIMS: Current society guidelines recommend antibiotic prophylaxis for 3 to 5 days after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions (PCLs). The overall quality of the evidence supporting this recommendation is low. In this study, we aimed to assess cyst infection and adverse event rates after EUS-FNA of PCLs among patients treated with or without postprocedural prophylactic antibiotics. METHODS: We retrospectively reviewed all patients who underwent EUS-FNA of PCLs between 2015 and 2019 at two large-volume academic medical centers with different practice patterns of postprocedural antibiotic prophylaxis. Data on patient demographics, cyst characteristics, fine-needle aspiration technique, periprocedural and postprocedural antibiotic prophylaxis, and adverse events were retrospectively extracted. RESULTS: A total of 470 EUS-FNA procedures were performed by experienced endosonographers for the evaluation of PCLs in 448 patients, 58.7% of whom were women. The mean age was 66.3±12.8 years. The mean cyst size was 25.7±16.9 mm. Postprocedural antibiotics were administered in 274 cases (POSTAB+ group, 58.3%) but not in 196 cases (POSTAB- group, 41.7%). None of the patients in either group developed systemic or localized infection within the 30-day follow-up period. Procedure-related adverse events included mild abdominal pain (8 patients), intra-abdominal hematoma (1 patient), mild pancreatitis (1 patient), and perforation (1 patient). One additional case of pancreatitis was recorded; however, the patient also underwent endoscopic retrograde cholangiopancreatography. CONCLUSION: The incidence of infection after EUS-FNA of PCLs is negligible. Routine use of postprocedural antibiotics does not add a significant benefit.

An international study of interobserver variability of "string sign" of pancreatic cysts among experienced endosonographers.

BACKGROUND AND OBJECTIVES: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the "string sign" test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. METHODS: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: "Is the string sign positive?" and "If the string sign is positive, what is the length of the formed string?" Also asked "What is the cutoff length for string sign to be considered positive?" Interobserver variability was assessed using the kappa statistic (κ). RESULTS: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. CONCLUSION: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.

Endoscopic ultrasound-guided fine needle aspiration for smooth benign appearing esophageal stricture due to metastatic breast cancer.

Metastatic breast cancer is an uncommon cause of esophageal stricture. We present an 80 year-old woman with past medical history of locally advanced breast cancer who admitted for evaluation of dysphagia. Barium swallow (i.g. esophageal fluoroscopy) demon-strated moderate irregular narrowing in the distal thoracic esophagus. Endoscopy revealed distal esophageal stricture with normal esophageal mucosa and computed tomography demonstrated thickened wall in the distal esophagus and the proximal stomach. Endoscopic biopsy of esophagus revealed no malignancy. Thus, we performed endoscopic ultrasound-guide fine needle aspiration (EUS-FNA) and cytological results were consistent with metastatic breast cancer. Diagnosis of malignant esophageal stricture due to metastasis from other primary is often challenging and requires a high index of suspicion. EUS-FNA is an alternative diagnostic technique in such cases when endoscopic biopsy fails to obtain adequate specimen.

Repeat endoscopic ultrasound-guided fine needle aspiration for solid pancreatic lesions at a tertiary referral center will alter the initial inconclusive result.

BACKGROUND & AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is indispensable for the diagnosis of solid pancreatic lesions (SPLs). However, initial attempt of EUS-FNA can be inconclusive. We retrospectively evaluated the ability of repeat EUS-FNA at a tertiary referral hospital to obtain a conclusive cytological diagnosis after the initial inconclusive EUS-FNA results at referring facilities. METHODS: We identified patients who had undergone EUS-FNA for SPLs and with inconclusive cytological diagnosis at referring facilities. The diagnostic ability of EUS-FNA was defined as the percentage of cases with conclusive cytological diagnoses out of the total included cases in which initial results had been inconclusive. As a secondary outcome, we conducted sub-group analysis to reveal factors which might have assisted conclusive results at the University of Texas MD Anderson Cancer Center (MDA). RESULTS: We found 913 patients who underwent EUS-FNA for SPLs between 2005 and 2011. Among them, we recruited 84 patients who met the above criteria. Repeat EUS-FNA had ability to clarify the diagnosis in 82.1 % (69/84). No statistical differences were observed in tumor size (n = 50, 29.8 versus 29.4 mm, P-value = 0.84) and the number of needles passes (n = 40, 4.0 versus 3.4, P-value = 0.1) between outside MDA and MDA. Rapid on-site evaluation was present in less than half of cases outside MDA (n = 33, 42.4 versus 100%, P-value = 0.0001). MDA endosonographers had more years of experience compared to outside MDA (n = 50, 12.9 versus 10 years, P-value = 0.015). CONCLUSIONS: A repeat EUS-FNA for SPLs with initial inconclusive diagnosis at a tertiary referral center establishes a diagnosis in the majority of patients.