Enteral free water vs. parenteral dextrose 5% in water for the treatment of hypernatremia in the intensive care unit: a retrospective cohort study from a mixed ICU.

PURPOSE: Effective treatment options for patients with hypernatremia are limited. Free water administration (parenterally or enterally) is the mainstay of treatment but the impact of each strategy on lowering serum sodium (Na) is not known. The purpose of the study was thus to assess the effectiveness of enteral free water vs. parenteral dextrose 5% in water (D5W) in treating ICU-acquired hypernatremia. METHODS: An electronic medical record-based, retrospective cohort study was conducted in a 30-bed mixed medical-surgical intensive care unit (ICU) in Japan. All adult patients admitted to the ICU from August 2017 to July 2021 were reviewed. After a 2-step exclusion, patients who stayed in the ICU ≥ 24 h and received either or both treatments for ICU-acquired hypernatremia (Na ≥ 145 mEq/L) constituted the study cohort. The primary outcome was a change in serum Na during the 24 h before treatment each day (ΔNa); the secondary outcomes were gastrointestinal complications, serum glucose levels, ICU/hospital mortality, ICU/hospital length of stay, and the duration of mechanical ventilation. Repeated measurements on each patient were addressed using a generalized estimated equation (GEE) for multiple linear regression analysis. Analysis was conducted with R version 4.0.3. RESULTS: In total, 256/6596 (131: D5W, 125: enteral free water) patients were analyzed. Median treatment lasted 6 days [3-17] for the D5W group vs 7 days [3-14] for the enteral free water group with a total median daily treatment volume of 799 [IQR 299-1221] mL vs. 400 [IQR 262-573] mL. GEE multiple linear regression analysis showed an estimated mean ΔNa per liter of treatment fluid of - 2.25 [95% CI - 2.76 to - 1.74] mEq/L per liter of parenteral D5W vs. - 1.91 mEq decrease [95% CI - 2.75 to - 1.07] per liter of enteral free water. Hydrochlorothiazide was the only medication associated with a statistically significant negative ΔNa by- 0.89 [- 1.57 to - 0.21] mEq/L. There were no significant inter-group differences for secondary outcomes. CONCLUSIONS: These results suggest that both enteral free water and parenteral D5W are effective for treating ICU-acquired hypernatremia. Parenteral D5W was slightly more effective than enteral free water to lower serum Na levels in patients with ICU-acquired hypernatremia. TRIAL REGISTRATION: Not applicable.

The effect of proton pump inhibitors and vonoprazan on the development of 'gastric mucosal redness'.

The safety of long-term proton pump inhibitor (PPI) and vonoprazan (VPZ) use is a relatively recent concern. Gastric mucosal redness was reported as a VPZ-associated lesion in a previous study. The aim of this study was to investigate the prevalence and risk factors for gastric mucosal redness. Between December 2020 and November 2021, 1,101 patients who underwent esophagogastroduodenoscopy were reviewed. The cohort was divided into four groups: Control (n=580), histamine-2 receptor antagonist (H2RA) (n=65), PPI (n=146) and VPZ groups (n=310). Gastric mucosal redness was present in 48/1,101 patients (4%). The prevalence in controls, H2RA, PPI and VPZ groups was 1.9% (11/580), 1.5% (1/65), 6.2% (9/146) and 8.7% (27/310), respectively. Both the PPI and VPZ groups had a significantly higher prevalence of gastric mucosal redness compared with the control group (P<0.001). In the multivariate analysis, PPI and VPZ use were significantly associated with gastric mucosal redness. Fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like mucosa, and stardust gastric mucosa were also significantly associated with PPI and VPZ use in the multivariate analysis. Back-to-back analysis showed that gastric mucosal redness was not seen before starting PPI/VPZ in most patients. The duration of treatment with VPZ was investigated to determine if it affected the prevalence of gastric mucosal redness. There were no significant differences in treatment duration among patients with and without gastric mucosal redness (mean ± standard deviation: 3.0±1.5 vs. 2.5±1.4 years, P=0.077). In conclusion, the prevalence of gastric mucosal redness was low but was associated with PPI and VPZ use.

Dopamine use and its consequences in the intensive care unit: a cohort study utilizing the Japanese Intensive care PAtient Database.

BACKGROUND: Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. The aim of this study was to identify the latest practice of dopamine use in Japan and also to explore the consequences of dopamine use in a large Asian population. METHODS: The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 h or more, and 4) treatment with either dopamine or noradrenaline within 24 h of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a propensity score-matched analysis. RESULTS: Of the 132,354 case records, 14,594 records from 56 facilities were included in this analysis. Dopamine was administered to 4,653 patients and noradrenaline to 11,844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p < 0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p < 0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71-1.04] in the dopamine ≤ 5 µg/kg/min group, 1.46 [95% CI: 1.18-1.82] in the 5-15 µg/kg/min group, and 3.30 [95% CI: 1.19-9.19] in the > 15 µg/kg/min group. In a 1:1 propensity score matching for dopamine use as a vasopressor (570 pairs), both in-hospital mortality and ICU mortality were significantly higher in the dopamine group compared to no dopamine group (22.5% vs. 17.4%, p = 0.038; 13.3% vs. 8.8%, p = 0.018), as well as ICU length of stay (mean 9.3 days vs. 7.4 days, p = 0.004). CONCLUSION: Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose. Trial registration Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.

Endoscopic ultrasound-guided pancreatic sampling for the histopathological diagnosis of autoimmune pancreatitis.

Autoimmune pancreatitis (AIP), which is characterized by pancreatic enlargement and irregular narrowing of the main pancreatic duct, is difficult to differentiate from malignancy. The irregular narrowing of the pancreatic duct, which can be detected via endoscopic retrograde cholangiopancreatography, is a characteristic feature of AIP; however, distinguishing between localized AIP and pancreatic cancer based on pancreatic duct imaging is difficult. This study overviews the efficacy of endoscopic ultrasound (EUS)-guided pancreatic sampling for the histopathological diagnosis of AIP. Recent enhancements in needle biopsy methodologies and technologies have contributed to improvement in the diagnostic efficacy of this technique. The guidance provided in this study for the histological diagnosis of AIP is anticipated to further advance in the histopathological diagnosis of AIP using EUS-guided pancreatic sampling.

Usefulness of linked color imaging for the detection of obscure early gastric cancer: Multivariate analysis of 508 lesions.

OBJECTIVES: Early gastric cancers (EGCs) of the elevated type or with submucosal invasion are easily found by routine endoscopy. However, most early cancers are challenging to detect because of subtle morphological or color differences from surrounding atrophic mucosa and intestinal metaplasia. Linked color imaging (LCI) enhances mucosal color difference, making it easier to detect EGCs. The aim of this study is to clarify the advantages and possible disadvantages of LCI for screening for obscure EGC. METHODS: A total of 665 malignant gastric lesions resected using endoscopic submucosal dissection between January 2015 and April 2018 were retrospectively reviewed. Obviously detectable lesions were not included in the main analysis when determining the target lesion. White light imaging (WLI)/LCI images of 508 endoscopically obscure malignant lesions were included in the final analysis and evaluated by three non-expert and three expert endoscopists using visibility scores for detection and extent. RESULTS: The detection visibility scores using LCI were significantly higher than those using WLI regardless of lesion characteristics including location, size, histological type, depth of invasion, and Helicobacter pylori status. The detection score improved in 46.4% cases and deteriorated in 4.9% when the modality changed from WLI to LCI. A mixed-effects multivariate logistic regression analysis showed that use of LCI (odds ratio [OR] 2.57), elevated type (OR 1.92), invasion to submucosa (OR 2.18) were significantly associated with improved visibility of EGC. CONCLUSIONS: Linked color imaging significantly improves visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and H. pylori status compared to conventional WLI.

Machine learning in gastrointestinal surgery.

Machine learning (ML) is a collection of algorithms allowing computers to learn directly from data without predetermined equations. It is used widely to analyze "big data". In gastrointestinal surgery, surgeons deal with various data such as clinical parameters, surgical videos, and pathological images, to stratify surgical risk, perform safe surgery and predict patient prognosis. In the current "big data" era, the accelerating accumulation of a large amount of data drives studies using ML algorithms. Three subfields of ML are supervised learning, unsupervised learning, and reinforcement learning. In this review, we summarize applications of ML to surgical practice in the preoperative, intraoperative, and postoperative phases of care. Prediction and stratification using ML is promising; however, the current overarching concern is the availability of ML models. Information systems that can manage "big data" and integrate ML models into electronic health records are essential to incorporate ML into daily practice. ML is fundamental technology to meaningfully process data that exceeds the capacity of the human mind to comprehend. The accelerating accumulation of a large amount of data is changing the nature of surgical practice fundamentally. Artificial intelligence (AI), represented by ML, is being incorporated into daily surgical practice.

The Psoas Muscle Index Is Associated with Prognosis in Elderly Patients Undergoing Cardiovascular Surgery.

BACKGROUND: Sarcopenia is associated with poor outcomes in elderly patients. However, current surgical risk assessment tools for cardiovascular surgery do not include the impact of sarcopenia. OBJECTIVES: This study aimed to assess whether the psoas muscle index, a numerical score used to assess sarcopenia, is associated with outcomes in elderly patients undergoing cardiovascular surgery. METHODS: This nested case-control study evaluated patients aged ≥ 75 years who underwent elective cardiovascular surgery and were admitted to the intensive care unit at Jichi Medical University, Saitama Medical Center between January 1, 2016 and March 31, 2017. The case group (poor outcomes) included patients who either died or were transferred to a rehabilitation facility postoperatively. The control group (good outcomes) included patients who were discharged postoperatively. Clinical factors likely to affect patient outcomes were assessed, and the characteristics of the two outcome groups were compared using logistic regression analysis. RESULTS: In total, 183 patients were evaluated; among them, 137 and 46 patients were categorized to the good and poor outcome groups, respectively. The psoas muscle index was significantly associated with outcome (odds ratio: 0.25; 95% confidence interval: 0.14 - 0.43; P < 0.001). A psoas muscle index cut-off of 3.24 had a specificity, sensitivity, positive predictive value, and negative predictive value of 0.86, 0.63, 0.58, and 0.87, respectively, for predicting worse outcome at discharge. CONCLUSIONS: The psoas muscle index was strongly associated with discharge to home in patients aged ≥ 75 years who underwent elective cardiovascular surgery. This finding suggests that the psoas muscle index might be useful in identifying the eligibility of older patients for cardiovascular surgery.

Polyp detection algorithm can detect small polyps: Ex vivo reading test compared with endoscopists.

BACKGROUND AND STUDY AIMS: Small polyps are occasionally missed during colonoscopy. This study was conducted to validate the diagnostic performance of a polyp-detection algorithm to alert endoscopists to unrecognized lesions. METHODS: A computer-aided detection (CADe) algorithm was developed based on convolutional neural networks using training data from 1991 still colonoscopy images from 283 subjects with adenomatous polyps. The CADe algorithm was evaluated on a validation dataset including 50 short videos with 1-2 polyps (3.5 ± 1.5 mm, range 2-8 mm) and 50 videos without polyps. Two expert colonoscopists and two physicians in training separately read the same videos, blinded to the presence of polyps. The CADe algorithm was also evaluated using eight full videos with polyps and seven full videos without a polyp. RESULTS: The per-video sensitivity of CADe for polyp detection was 88% and the per-frame false-positive rate was 2.8%, with a confidence level of ≥30%. The per-video sensitivity of both experts was 88%, and the sensitivities of the two physicians in training were 84% and 76%. For each reader, the frames with missed polyps appearing on short videos were significantly less than the frames with detected polyps, but no trends were observed regarding polyp size, morphology or color. For full video readings, per-polyp sensitivity was 100% with a per-frame false-positive rate of 1.7%, and per-frame specificity of 98.3%. CONCLUSIONS: The sensitivity of CADe to detect small polyps was almost equivalent to experts and superior to physicians in training. A clinical trial using CADe is warranted.

The linkage between medical student readiness for interprofessional learning and interest in community medicine.

OBJECTIVES: The purpose of this study is to investigate the relationship between medical student readiness for interprofessional learning and interest in community medicine prior to incorporating community-oriented interprofessional education into the curriculum. METHODS: A questionnaire was administered to students at Nagasaki University School of Medicine in Japan during each of three consecutive years (N=2244). The Readiness for Interprofessional Learning Scale (RIPLS) was administered in addition to a questionnaire to evaluate interest in community medicine. The Kruskal-Wallis and Steel-Dwass tests were used to determine differences between school years. Correlation between the RIPLS score and interest in community medicine was evaluated with Spearman's rank correlation coefficient. Relationships between RIPLS score and demographic parameters, and interest in community medicine were evaluated with multiple linear regression analysis. RESULTS: Eighty-four percent (1891/2244) of students responded. The RIPLS score was highest in school year 1, followed by year 6, year 5, year 3, and years 4 and 2. Interest in community medicine correlated with the RIPLS score (rs = 0.332, p < 0.001), but less in year 1 (rs = 0.125, p = 0.002) than in other years. RIPLS score was significantly associated with gender, age, school year, interest in community medicine, but not the year that the survey was conducted. CONCLUSIONS: Community-oriented interprofessional education has the potential to improve attitudes towards interprofessional learning. When introducing this promising education into the curriculum from year 1, attracting students' interest in community medicine should be considered.

Exosomal microRNA in peritoneal fluid as a biomarker of peritoneal metastases from gastric cancer.

AIM: Peritoneal metastases (PM) frequently occur in patients with gastric cancer and result in a poor prognosis. Exosomes play pivotal roles in tumor metastasis through the transfer of microRNAs (miRNAs). We examined the exosomal miRNA profile in peritoneal fluids to identify novel biomarkers to reflect tumor burden in the peritoneum. METHODS: Exosomes were isolated from peritoneal fluids of patients of gastric cancer with macroscopic (P1) or microscopic (P0CY1) peritoneal metastasis (PM) and comprehensive miRNA expression analysis was carried out. Expressions of candidate miRNAs were then validated in all 58 samples using TaqMan Advanced miRNA Assays. RESULTS: In initial screening, we carried out comprehensive analysis of exosomal miRNA using peritoneal fluids from 11 and 14 patients with or without PM, respectively, and identified 11 dysregulated miRNAs in PM (+) samples. Validation analysis showed that four miRNAs (miR-21-5p, miR-92a-3p, miR-223-3p, and miR-342-3p) were significantly upregulated in 12 PM (+) samples, and their expression levels showed positive correlation with peritoneal cancer index. In contrast, miR-29 family were all downregulated in patients with PM (+) samples. Moreover, in 24 patients with pT4 tumor, miR-29 at gastrectomy tended to be lower in six patients with peritoneal recurrence with significant differences in miR-29b-3p (P = .012). CONCLUSION: Expression pattern of miRNAs in peritoneal exosomes well reflects the tumor burden in the peritoneal cavity and could be a useful biomarker in the treatment of PM.

Mesocolic hernia after laparoscopic transverse colectomy: A case report.

INTRODUCTION: Internal hernias are rare after laparoscopic colorectal resections. We report a patient with an internal hernia through a defect in the transverse mesocolon following laparoscopic resection. PRESENTATION OF CASE: A 52-year-old male underwent laparoscopic colectomy for transverse colon cancer and had an unremarkable postoperative course. Thirty days postoperatively, he presented to the emergency room with sudden onset abdominal pain and vomiting. Enhanced abdominal computed tomography scan showed strangulated small intestine in the left upper abdomen. An internal hernia through the mesenteric defect created during the recent colon resection was suspected, and emergency laparotomy was performed. One hundred thirty cm of small intestine was found herniated through a mesenteric defect. After repositioning the ischemic-appearing intestine, a 5 cm defect in the transverse mesocolon was found which had not been closed during the previous laparoscopic operation. No intestinal resection was needed, and the mesenteric defect closed with non-absorbable sutures. The post-operative course was unremarkable except for paralytic ileus, which resolved without further intervention. DISCUSSION: The incidence of internal hernia through a mesenteric defect after laparoscopic colorectal resection is quite low. Therefore, routine closure of the mesenteric defect after laparoscopic colorectal resection is not required. However, a left sided defect in the transverse mesocolon might be at higher risk of causing an internal hernia on anatomic grounds. CONCLUSION: We believe that mesenteric defects should be closed after laparoscopic resection of the left side of transverse colon, regardless of their size.

Administration of Corticosteroids, Ascorbic Acid, and Thiamine Improves Oxygenation after Thoracoscopic Esophagectomy.

PURPOSE: The activity of corticosteroids, ascorbic acid, and thiamine against oxidative and inflammatory responses was evaluated in patients undergoing esophagectomy. This study was undertaken to investigate the effect of this combined therapy on lung dysfunction following esophagectomy. METHODS: In this retrospective before-after study, we compared the clinical course of consecutive patients undergoing thoracoscopic esophagectomy treated with the combination of corticosteroids, ascorbic acid, and thiamine between June and December 2018 with a control group treated with corticosteroids alone between January 2016 and May 2018. Outcomes included oxygenation (arterial partial pressure of oxygen (PaO2)/fractional concentration of inspired oxygen (FiO2) ratios), duration of mechanical ventilation and intensive care unit (ICU) length of stay. RESULTS: In all, 17 patients were included in this study (6 in the combination therapy group and 11 patients in the control group). Mean PaO2/FiO2 ratios in the combined therapy group were significantly higher than in the control group at all points during the observation period (p <0.001). In the combined therapy group, the duration of mechanical ventilation and ICU stay were significantly shorter (p <0.001, p = 0.009). CONCLUSIONS: This study suggests that combined therapy including corticosteroids, ascorbic acid, and thiamine may be effective in improving oxygenation after esophagectomy. Additional studies are required to confirm these preliminary findings.

Long-term outcomes of patients with symptomatic gastroesophageal reflux disease treated with vonoprazan.

OBJECTIVE: The novel potassium-competitive acid blocker, vonoprazan, provides rapid and effective acid suppression. The aim of this study is to evaluate the long-term outcomes of patients with symptomatic gastroesophageal reflux disease (GERD) treated with vonoprazan. METHODS: This retrospective cohort study included 55 patients with symptomatic GERD treated with vonoprazan who have been followed for more than one year. The effectiveness of vonoprazan on gastrointestinal symptoms was evaluated using the Izumo scale, a self-reported questionnaire reflecting quality of life related to various abdominal symptoms. RESULTS: These 55 patients with symptomatic GERD had non-erosive reflux disease (n = 30) or erosive esophagitis (n = 25). Vonoprazan (10 mg) for one month improved GERD symptoms in 89% (responders) and the improvement was maintained at one year in 82% without additional treatment. One-year maintenance therapy resulted in sustained resolution of GERD symptoms in 47%. Of the 49 responders, nine patients had relapse of GERD symptoms and dose escalation of vonoprazan improved the symptoms in six patients. Postprandial distress and the presence of erosive esophagitis before starting vonoprazan were identified as significant negative and positive predictors of sustained resolution of GERD symptoms for one year, respectively. Epigastric pain, postprandial distress, constipation and diarrhea were significantly improved at one-month and maintained at one year. After one-year of treatment, the endoscopic healing rate of erosive esophagitis was 95%. CONCLUSION: One-year treatment with vonoprazan significantly improves GERD symptoms and endoscopic healing of erosive esophagitis is satisfactory. The long-term use of vonoprazan is effective and useful to control GERD.

Balloon-assisted endoscopy facilitates endoscopic submucosal dissection of difficult superficial proximal colon tumors.

BACKGROUND: Colorectal endoscopic submucosal dissection (ESD) can be technically difficult in some situations, such as paradoxical movement of the proximal colon. The double-balloon endoscope provides stable endoscopic maneuvering, even in the small intestine. The aim of this study was to assess the outcomes of balloon-assisted endoscopic submucosal dissection (BAESD) of colonoscopically difficult superficial proximal colon tumors. METHODS: We retrospectively reviewed the records of patients who underwent BAESD of superficial proximal colon tumors where colonoscopic difficulties were encountered, from January 2011 to September 2016. Difficulties were defined as a previous incomplete colonoscopy using a conventional colonoscope or unstable endoscopic maneuverability around the tumor with a conventional colonoscope. A propensity score model was used as a secondary analysis to compare outcomes of the BAESD group with those of a non-BAESD group.  RESULTS: BAESD was performed on 63 tumors in 63 patients. En bloc resection was achieved for 62 tumors (98 %) and an R0 resection was achieved for 55 tumors (87 %). Propensity score matching analysis created 59 matched pairs from the BAESD and non-BAESD groups. There were no statistically significant differences between the two groups in en bloc resection (100 % vs. 100 %; P > 0.99), R0 resection (90 % vs. 93 %; P = 0.74), perforation (0 % vs. 2 %; P > 0.99) or postoperative bleeding (3 % vs. 0 %; P = 0.50). CONCLUSION: Balloon-assisted endoscopy achieved safe and reliable ESD of colonoscopically difficult superficial proximal colon tumors.

Colonoscopy in Patients Aged 85 Years or Older: An Observational Study.

OBJECTIVES: Colonoscopy is the first-line modality to examine the colon even in the very elderly but may have an increased risk of complications. This study aimed to evaluate the efficacy and safety of colonoscopy in the very elderly. METHODS: Patients ≥85y old, who underwent colonoscopy between September 2010 and August 2012 in two tertiary-care hospitals in Japan were enrolled. Main outcome measures were cecal intubation rate, detection rate of adenomas and cancers, treatment, adverse events, and long-term outcomes. RESULTS: A total of 207 colonoscopies were performed in 177 patients (females 72, males 105; maximum age 95 years). Of these, 202 attempted to reach the cecum, with success in 92%. Excluding patients with known colorectal neoplasms, invasive cancers were detected in 12%, including T1 lesions in 2% and T2 or deeper in 9%. No cancers were detected in patients referred for surveillance or mild abdominal symptoms. Cancers were found in 25% of patients with positive fecal immunochemical tests, 22% with altered bowel habits, 21% with anemia, and 18% with hematochezia. Treatment of 29 patients with cancer included surgery in 22, endoscopic resection in two and no treatment (due to comorbidities) in five. There were no complications. During 730 days (mean) of follow up, 27 patients died but only three died from recurrent colorectal cancer. CONCLUSIONS: Colonoscopy for patients aged ≥85 years is safe. A relatively high detection rate of cancers was found, and most were treatable and even curable. (UMIN000018575).

Intussusception due to an Inverted Meckel's Diverticulum Diagnosed by Double-Balloon Enteroscopy.

An 18-year-old man presented after undergoing multiple investigations for abdominal pain. Retrograde double-balloon enteroscopy showed a protruding red lesion in the ileum with small ulcers, approximately 75 cm proximal to the ileocecal valve, resulting in an intussusception. An inverted Meckel's diverticulum was strongly suspected. Pressure was applied to the protruding lesion using contrast medium injection after wedging the lumen with a balloon. The intussusception partially reduced, avoiding the need for emergent surgery. Endoscopic tattooing was performed to mark the lesion for subsequent resection. Elective laparoscopy-assisted surgery with minimum laparotomy revealed an inverted Meckel's diverticulum, which was resected.

Esophageal seeding after endoscopic ultrasound-guided fine-needle aspiration of a mediastinal tumor.

Background and study aims Tumor seeding after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is rare. A 53-year-old man underwent transesophageal EUS-FNA for diagnosis of a 6-cm mass in the mediastinum as seen by computed tomography (CT). Four weeks later, repeat CT scan revealed a mass in the esophageal wall. Upper gastrointestinal endoscopy confirmed a lesion in the mid-esophagus, which was biopsied and found to be consistent with needle tract seeding after EUS-FNA. Tumor seeding in the gastrointestinal wall or peritoneum after EUS-FNA is rare, but may adversely affect the prognosis. Indications for EUS-FNA must be carefully considered.