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Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts
We read with great interest the study by Kovacevic et al. entitled “Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts” . As this is only the second prospective study evaluating through-the-needle biopsy (TTNB) of pancreatic cysts, we congratulate the authors on their achievement and offer our contributions.
The authors report a substantial improvement in diagnostic yield with TTNB compared with cytologic fluid analysis, resulting in a clinical impact in 12 % of patients. However, they also report a significant risk of postoperative adverse events in 10 % of patients, including acute pancreatitis (n = 9) and significant intracystic hemorrhage (n = 1). The authors also report a 1 % mortality risk (n = 1). The cause for mortality is not defined. A recent systematic review and meta-analysis involving 426 patients undergoing TTNB reported a pooled adverse event rate of 7.0 %, yet no fatal events occurred . While the risk of adverse events is similar to previous reports, the authors present the only fatality among single and multicenter trials. The authors should have considered detailing the events that led to mortality and also stating whether this fatality occurred before or after the protocol amendment adding perioperative intravenous fluid and administration of nonsteroidal anti-inflammatory drugs (NSAIDs). These details might significantly alter the preprocedural risk stratification and selection of patients suitable to undergo TTNB. Additionally, if this fatality occurred prior to the protocol amendment, it would further strengthen the practice of perioperative hydration and NSAID use.
The classification of severity for the postoperative adverse events needs to be mentioned. For acute pancreatitis, the standard approach is to classify acute pancreatitis using the Revised Atlanta Classification . Another key issue is to classify adverse events by the cyst diagnosis. In our experience using the 19 G for endoscopic ultrasound-guided needle-based confocal endomicroscopy, there were no events of post-procedural acute pancreatitis among those with serous cystadenomas .
17 December 2020 (online)
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- 1 Kovacevic B, Klausen P, Rift CV. et al. Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts. Endoscopy 2020; DOI: 10.1055/a-1214-6043.
- 2 Westerveld DR, Ponniah SA, Draganov PV. et al. Diagnostic yield of EUS-guided through-the-needle microforceps biopsy versus EUS-FNA of pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8: E656-E667
- 3 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
- 4 Krishna SG, Hart PA, Malli A. et al. Endoscopic ultrasound-guided confocal laser endomicroscopy increases accuracy of differentiation of pancreatic cystic lesions. Clin Gastroenterol Hepatol 2020; 18: 432-440.e6