• Endoscopic ultrasonography
• Endoscopy Lower GI Tract
• Endoscopy Upper GI Tract
• Pancreatobiliary (ERCP/PTCD)
• Quality and logistical aspects
• Quality management

• EUS
• FNA
• cyst
• infection
• pancreas

• bleeding
• complications
• endoscopic ultrasound-guided fine-needle aspiration
• infection
• morbidity
• mortality
• needle tract seeding
• pancreatitis
• perforation

Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bacteremia (PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage. However, the current recommendations may not cover all potential risk factors for PEB.

To identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis.

A retrospective study of 1082 ERCP procedures performed between January 2012 - December 2013 in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures. Exclusion criteria were: (1) Age < 18 years; (2) Positive bacterial blood culture before ERCP; (3) Scheduled antibiotic treatment prior to ERCP; (4) Hospitalization longer than 14 d before ERCP; and (5) missing critical data. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.

A total of 626 ERCPs performed in 434 patients were included. Mean age 66.49 ± 15.4 years and 46.5% were males. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 139/626 (22.2%) cases but was indicated according to the guidelines only in 44/626 (7%) cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression [receiver operating characteristic (ROC), 0.766], identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years (OR, 3.780, 95%CI: 1.519-9.408, P = 0.004); Tandem EUS/ERCP with fine needle aspiration (FNA) (OR, 14.528, 95%CI: 3.571-59.095, P < 0.001); ERCP duration longer than 60 min (OR, 5.396, 95%CI: 1.86-15.656, P = 0.002). In a decision tree model (ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration. 

The prevalence of PEB in our study is similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. These factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.

• Endoscopic retrograde cholangiopancreatography
• Bacteremia
• Tandem-procedures
• Fine needle aspiration
• Antibiotic prophylaxis
• Biliary drainage

• Adolescent
• Aged
• Aged, 80 and over
• Bacteremia/epidemiology
• Bacteremia/etiology
• Bacteremia/prevention & control
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Endosonography
• Female
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Risk Factors

• Adverse Events
• Endoscopy
• Infection
• Prophylaxis

Contrast enhanced harmonic endoscopic ultrasound (CEH-EUS) is a spreading technique; some studies have shown its value in the diagnosis of pancreatic adenocarcinoma using quantitative analysis.

To examine the value of CEH-EUS for differentiating various pancreatic lesions in everyday routine with qualitative and quantitative analysis.

Data of 55 patients with pancreatic lesions who underwent CEH-EUS were analysed retrospectively. Perfusion characteristics were classified by the investigator qualitatively immediately upon investigation, quantitative analysis was performed later on. Samples from fine needle aspiration (EUS-FNA) or surgical specimen served as gold standard.

CEH-EUS showed 39 hypoenhanced lesions, 3 non-enhanced and 13 hyperenhanced lesions. Concordance of the investigators qualitative classification of peak contrast enhancement with quantitative analysis later on was 100%, while other parameters such as arrival time, time to peak or area under the curve did not show additional value. 34 of 39 hypoenhanced lesions were pancreatic adenocarcinoma; of the hyperenhanced lesions 4 were inflammatory, 3 neuroendocrine carcinomas, 1 lymphoma, 1 insulinoma and 4 metastases (2 of renal cell carcinoma, 2 of lung cancer). Non-enhanced lesions showed up as necroses. Sensitivity for the detection of pancreatic adenocarcinoma was 100%, specificity 87.2% for hypoenhancement alone; in otherwise healthy pancreatic tissue all hypoenhanced lesions were pancreatic adenocarcinoma (sensitivity and specificity 100%, PPV and NPV for adenocarcinoma 100%).

This study again shows the excellent value of CEH-EUS in everyday routine for diagnostics of various focal pancreatic lesions suggesting that qualitatively assessed hypoenhancement is highly predictive for adenocarcinoma. Additional quantitative analysis of perfusion parameters does not add diagnostic yield. In case of the various hyperenhanced pancreatic lesions in our data set, histologic sampling is essential for further treatment.

• Endoscopic ultrasound
• Contrast enhanced endoscopic ultrasound
• Pancreatic adenocarcinoma
• Neuroendocrine carcinoma
• Pancreatic metastases
• Lymphoma

• EUS
• EUS-tissue acquisition
• Early pancreatic cancer
• Staging

Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is universally used for the investigation and diagnosis of pancreatic cystic lesions (PCL). Infectious complications following EUS-FNA of PCL are rare. Antibiotic prophylaxis to reduce the risk of infection is recommended; however, there is no consensus on the optimal regimen or route of administration. Potential advantages of a single-dose intravenous (IV) antibiotic over a prolonged oral regimen include simplicity, guaranteed delivery and fewer antibiotic related adverse events, but there are only limited data to support this. We aimed to investigate the safety and efficacy of a single 1 g dose of IV ceftriaxone in preventing infectious complications following EUS-FNA of PCL.

A retrospective analysis was conducted of EUS-FNA of PCL procedures performed at our center. We reviewed patient medical records for any presentation to a hospital in our district within 30 days of the procedure. An infectious complication was defined as fever/rigors, or bacteremia, or abdominal pain accompanied by imaging or laboratory results suggestive of infection, within 30 days of the procedure. Data collection included patient demographics, procedural data and outcome.

EUS-FNA of 204 PCL (mean size 18.0 mm) was performed. Successful fluid aspiration was achieved in 94% of cases. Single-dose IV ceftriaxone was given in 146/204 (72%) cases. Four patients had a complication (pancreatitis n=1, post-procedural pain n=3). No infectious complications and no IV antibiotic-related adverse events were identified.

A single dose of IV ceftriaxone appears to be a safe, effective and convenient intervention for preventing infectious complications after FNA.

• Endoscopic ultrasound
• antibiotics
• fine-needle aspiration
• infectious complications

The diagnostic approach to a possible pancreatic mass lesion relies first upon various non-invasive imaging modalities, including computed tomography, ultrasound, and magnetic resonance imaging techniques. Once a suspect lesion has been identified, tissue acquisition for characterization of the lesion is often paramount in developing an individualized therapeutic approach. Given the high prevalence and mortality associated with pancreatic cancer, an ideal approach to diagnosing pancreatic mass lesions would be safe, highly sensitive, and reproducible across various practice settings. Tools, in addition to radiologic imaging, currently employed in the initial evaluation of a patient with a pancreatic mass lesion include serum tumor markers, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). EUS-FNA has grown to become the gold standard in tissue diagnosis of pancreatic lesions.

• Endoscopic ultrasound
• Fine needle aspiration
• Pancreatic cancer
• Pancreatic mass
• Endoscopy

• Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
• Endoscopy/methods
• Endosonography/methods
• Evidence-Based Medicine/methods
• Hemorrhage/diagnostic imaging
• Humans
• Infections/diagnostic imaging
• Neoplasm Staging/methods
• Pancreas/diagnostic imaging
• Pancreatic Neoplasms/diagnostic imaging
• Pancreatitis/diagnostic imaging
• Prevalence
• Randomized Controlled Trials as Topic
• Reproducibility of Results
• Sensitivity and Specificity
• Ultrasonography/methods

• Complications of EUS
• EUS guided FNA
• EUS guided PD drainage
• EUS guided biliary drainage
• EUS guided drainage of pancreatic fluid collection

Endoscopic ultrasound (EUS)-guided tissue acquisition has emerged over the last decade as an invaluable diagnostic tool in approaching the different pancreatic lesions. Given the safety and minimal invasiveness of this approach combined with the high diagnostic yield, it became the standard of care when dealing with different pancreatic pathologies. However, some variables regarding this procedure remain not fully understood. These can influence the diagnostic yield of the procedure and include the presence of the on-site cytopathologist, the type and size of the needle used as well as obtaining aspiration versus core biopsy, the number of passes and the sampling technique, and the role of suction and stylet use among others. We performed a comprehensive literature search using PubMed, Google Scholar, and Embase for studies that assessed these variables. Eligible studies were analyzed using several parameters such as technique and procedure, with the aim of reviewing results from an evidence-based standpoint.

• Cytopathology
• endoscopic ultrasound (EUS)
• fine-needle aspiration (FNA)
• fine-needle biopsy (FNB)
• pancreatic lesions

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been applied to pancreaticobiliary lesions since the 1990s and is in widespread use throughout the world today. We used this method to confirm the pathological evidence of the pancreaticobiliary lesions and to perform suitable therapies. Complications of EUS-FNA are quite rare, but some of them are severe. Operators should master conventional EUS observation and experience a minimum of 20-30 cases of supervised EUS-FNA on non-pancreatic and pancreatic lesions before attempting solo EUS-FNA. Studies conducted on pancreaticobiliary EUS-FNA have focused on selection of suitable instruments (e.g., needle selection) and sampling techniques (e.g., fanning method, suction level, with or without a stylet, optimum number of passes). Today, the diagnostic ability of EUS-FNA is still improving; the detection of pancreatic cancer (PC) currently has a sensitivity of 90%-95% and specificity of 95%-100%. In addition to PC, a variety of rare pancreatic tumors can be discriminated by conducting immunohistochemistry on the FNA materials. A flexible, large caliber needle has been used to obtain a large piece of tissue, which can provide sufficient histological information to be helpful in classifying benign pancreatic lesions. EUS-FNA can supply high diagnostic yields even for biliary lesions or peri-pancreaticobiliary lymph nodes. This review focuses on the clinical aspects of EUS-FNA in the pancreaticobiliary field, with the aim of providing information that can enable more accurate and efficient diagnosis.

• Endoscopic ultrasonography-guided fine-needle aspiration
• Diagnosis
• Pancreaticobiliary
• Pancreatic
• Cancer

• Biliary Tract Neoplasms/pathology
• Biliary Tract Neoplasms/therapy
• Clinical Competence
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/adverse effects
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/instrumentation
• Equipment Design
• Humans
• Learning Curve
• Needles
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/therapy
• Predictive Value of Tests
• Prognosis
• Reproducibility of Results
• Risk Factors

Background. The bacteremia is reported as being infrequent and transient in gastric EMR and ESD for treating gastric mucosa lesions or superficial gastric neoplastic lesion. There was no report of it being investigated in ESD for treating gastric muscular layer tumors (endoscopic submucosal excavation, ESE). This study aimed to determine the frequency of bacteremia in gastric ESE. Patients and Methods. A prospective study, in 122 consecutive patients who underwent gastric ESE for treating gastric muscular layer tumors, investigated the frequency of bacteremia before and 15 minutes after the procedure. Results. The median time for the total ESE procedure was 29 min (range from 8 to 62 min). The mean size of the biggest diameter of each resected specimen was 10 ± 2.7 mm (range from 5 mm to 30 mm). Blood cultures obtained before ESE were positive in 0% (0/122) of cases. Blood cultures obtained 15 min after ESE were positive in 2.5% (3/122) of cases. Six blood samples contained Staphylococcus with coagulase negative, which was considered contaminant. No signs of sepsis were seen in all patients. Conclusions. The frequency of bacteremia after gastric ESE was low. ESE for treating gastric lesions is thought to have a low risk of infectious complications; therefore, prophylactic administration of antibiotics may not be warranted.

• Anti-Bacterial Agents/therapeutic use
• Antibiotic Prophylaxis/standards
• Bacterial Infections/prevention & control
• Endoscopy, Gastrointestinal/standards
• Humans

• Endoscopic ultrasonography
• Pancreatic cancer
• Surveillance

Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is often the preferred technique for tissue acquisition in the diagnosis of suspected intrathoracic and intraabdominal pathology. Although EUS FNA is a safe and accurate procedure, it has been associated with a low risk of adverse events. The unique properties of the echoendoscope and its ability to acquire tissue outside of the gastrointestinal lumen impart risks that are not associated with routine endoscopic procedures. In this review, we discuss the risk of perforation related to the echoendoscope itself and adverse events related to FNA of solid masses including infections, bleeding, pancreatitis and pancreatic duct leak, bile duct leak and tumor seeding. We also provide tips on how to avoid the most common adverse events related to EUS-FNA.

• Bleeding
• infection
• pancreatitis
• perforation

• bacteremia
• blood culture
• endoscopic ultrasonography
• fine needle aspiration
• povidone-iodine solution
• proton pump inhibitor

• Neoplasms, cystic, mucinous, and serous
• Pancreatic cyst
• Pancreatic neoplasms

• Bacteremia/etiology
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/adverse effects
• Endosonography/adverse effects
• Esophageal Perforation/etiology
• Gastrointestinal Neoplasms/diagnosis
• Humans
• Intestinal Perforation/etiology
• Pancreatitis/etiology
• Peritonitis/etiology
• Postoperative Hemorrhage/etiology

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.

• Endoscopic ultrasonography
• Endoscopic ultrasonography-guided fine-needle biopsy
• Complications
• Contraindications
• Risk
• Safety
• Perforation
• Bleeding
• Infection
• Acute pancreatitis

• Aged
• Aged, 80 and over
• Anti-Bacterial Agents/therapeutic use
• Antibiotic Prophylaxis
• Bacterial Infections/etiology
• Bacterial Infections/prevention & control
• Biopsy, Fine-Needle/adverse effects
• Cohort Studies
• Endosonography/adverse effects
• Female
• Humans
• Male
• Middle Aged
• Pancreatic Cyst/diagnostic imaging
• Pancreatic Cyst/pathology
• Retrospective Studies

• Aged
• Anti-Bacterial Agents/therapeutic use
• Biopsy, Needle/adverse effects
• Diagnosis, Differential
• Endocarditis, Bacterial/diagnosis
• Endocarditis, Bacterial/drug therapy
• Endocarditis, Bacterial/etiology
• Endosonography/methods
• Follow-Up Studies
• Humans
• Lung Neoplasms/diagnostic imaging
• Lung Neoplasms/pathology
• Lymph Nodes/diagnostic imaging
• Lymph Nodes/pathology
• Lymphatic Metastasis
• Male
• Mediastinum
• Rare Diseases
• Streptococcal Infections/diagnosis
• Streptococcal Infections/drug therapy
• Streptococcal Infections/etiology
• Streptococcus/isolation & purification
• Tomography, X-Ray Computed

• Endosonography
• Humans
• Neoplasm Staging
• Pancreatic Neoplasms/diagnostic imaging

• Biopsy, Needle/instrumentation
• Endoscopes, Gastrointestinal
• Endosonography/instrumentation
• Endosonography/methods
• Equipment Design
• Humans
• Needles
• Ultrasonography, Interventional/instrumentation

• Costs and Cost Analysis
• Endosonography/economics
• Endosonography/instrumentation
• Equipment Design/economics
• Equipment Design/instrumentation
• Equipment Safety
• Gastrointestinal Diseases/diagnostic imaging
• Gastrointestinal Neoplasms/diagnostic imaging
• Humans
• Technology Assessment, Biomedical

• Lung Neoplasms/diagnosis

• Adenocarcinoma/pathology
• Adult
• Aged
• Aged, 80 and over
• Antibiotic Prophylaxis
• Bacteremia/epidemiology
• Bacteremia/etiology
• Bacteremia/prevention & control
• Biopsy, Needle/adverse effects
• Colorectal Neoplasms/pathology
• Comorbidity
• Endocarditis, Bacterial/prevention & control
• Endoscopy, Digestive System
• Endosonography
• Female
• Heart Diseases/epidemiology
• Humans
• Male
• Middle Aged
• Prospective Studies
• Rectal Neoplasms/pathology
• Risk Assessment
• Sigmoidoscopy