Background: A dilated main pancreatic duct (MPD) ≥ 5 mm can be observed in main-duct IPMNs (MD-IPMN) and chronic pancreatitis (CP); however, distinguishing between the two differently treated diseases can be difficult. Cell-free (cf) DNA in MPD fluid obtained by EUS-guided FNA might help to distinguish MD-IPMN from CP. Methods: All patients with a dilated MPD ≥ 5 mm on EUS during the period of 1 June 2017 to 30 April 2024 were prospectively analysed in this single-centre study, with EUS-guided MPD fluid aspiration performed for suspected MD-IPMN or CP in patients who were suitable for surgery. Twenty-two known gastrointestinal cancer genes, including GNAS and KRAS, were analysed by deep targeted (dt) NGS. The results were correlated with resected tissue, biopsy, and long-term follow-up. Results: A total of 164 patients with a dilated MPD were identified, of which 30 (18.3%) underwent EUS-guided FNA, with 1 patient having a minor complication (3.3%). Twenty-two patients (mean MPD diameter of 12.4 (7–31) mm) with a definitive, mostly surgically confirmed diagnosis were included in the analysis. Only a fish-mouth papilla, which was present in 3 of 12 (25%) MD-IPMNs, could reliably differentiate between the two diseases, with history, symptoms, diffuse or segmental MPD dilation, presence of calcifications on imaging, cytology, and CEA in the ductal fluid failing to achieve differentiation. However, GNAS mutations were found exclusively in 11 of the 12 (91.6%) patients with MD-IPMN (p < 0.01), whereas KRAS mutations were identified in both diseases. Conclusions: GNAS testing by dtNGS in aspirated fluid from dilated MPD obtained by EUS-guided FNA may help differentiate MD-IPMN from CP for surgical resection.

BACKGROUND:The prevalence of pancreatic cyst lesions in the general population worldwide is 16%. The majority of these cysts are intraductal papillary mucinous neoplasms (IPMN), which are associated with a risk of developing pancreatic cancer. In this article, we summarize the current knowledge of the differential diagnosis and management of cystic pancreatic neoplasms. METHODS:This narrative review is based on a selective search for pertinent literature (1 January 2014 to 9 January 2025). RESULTS:Most cysts are less than 10 mm in diameter and have practically no potential for malignant transformation. If a small cyst remains unchanged in the absence of risk factors, monitoring can be ended five years after initial detection. Magnetic resonance imaging (MRI) is the best method of characterizing and following up such lesions. If the diagnosis is unclear, endosonography should be performed. For IPMN, the most common type of pancreatic cystic neoplasm, the international Kyoto guideline 2024 contains a revised management algorithm based on risk factors. IPMN with high-grade dysplasia is an ideal indication for surgical resection. Serous cystic adenomas should generally not be operated on, and mucinous cystic neoplasia or a cystic neuroendocrine tumor of the pancreas should be operated on only if it has reached a certain size. Minimally inva - sive and parenchyma-sparing techniques are now being increasingly used in pancreatic surgery. CONCLUSION:Oncological criteria as well as potential surgical risks and long-term sequelae must enter into the decision whether a pancreatic lesion should be resected. Exocrine and endocrine insufficiency are relevant and sometimes irreversible complications.

Background Idiopathic and secondary megacolon (MC) and megarectum (MR) in adults is associated with persistent bowel dilatation and reduced intestinal motility. Little is known about the optimal treatment of this rare disease. Therefore, we retrospectively analysed long-term data from these patients in 5 community and university hospitals, focusing on conservative versus surgical treatment. Methods Patient records from 7/2004 to 9/2021 were screened for colorectal diseases with severe constipation and persistent megacolon >= 9.0 cm and/or megarectum >= 6.5 cm. Follow up-data was collected through telephone interviews and written surveys. ClinicalTrialsgov NCT04340856. Results Sixty-seven patients with idiopathic (n=10) and secondary (n=57) MC or MR were identified with only 20 of 67 patients (29.9%) correctly diagnosed. Mean/median age was 64/69 (range 18-93) years. Thirty-two patients were treated with laxative regimens, and 35 underwent surgery (colostomy: n=12, segmental resection, or hemicolectomy: n=10, (sub)total colectomy: n= 13) after conservative treatment attempts in 32/35 (91.4%). The mean/median follow-up was 4.2/2.7 (range 0.1-17.0) years. The readmission rate for MC-associated symptoms was significantly higher after conservative treatment than after surgical therapy at 12 (0.84 vs. 0.36 per patient, p=0.036), 24 (1.00 vs. 0.52, p=0.048) and 36 (1.13 vs. 0.58, p=0.047) months, as was the number of patients with persistent laxative dependence (28/32 (87.5%) vs. 19/33 (57.6%); p = 0.007). Therapy-associated adverse events (Clavien-Dindo classification) were documented more often in surgically treated patients (11/35, 31.4%) (p=0.025). Conclusion Surgical treatment may be considered earlier if idiopathic or secondary MC or MR is correctly diagnosed, and conservative treatment has been attempted.

Background Idiopathic and secondary megacolon (MC) and megarectum (MR) in adults is associated with persistent bowel dilatation and reduced intestinal motility. Little is known about the optimal treatment of this rare disease. Therefore, we retrospectively analysed long-term data from these patients in 5 community and university hospitals, focusing on conservative versus surgical treatment. Methods Patient records from 7/2004 to 9/2021 were screened for colorectal diseases with severe constipation and persistent megacolon ≥ 9.0 cm and/or megarectum ≥ 6.5 cm. Follow up-data was collected through telephone interviews and written surveys. ClinicalTrialsgov NCT04340856. Results Sixty-seven patients with idiopathic (n=10) and secondary (n=57) MC or MR were identified with only 20 of 67 patients (29.9%) correctly diagnosed. Mean/median age was 64/69 (range 18–93) years. Thirty-two patients were treated with laxative regimens, and 35 underwent surgery (colostomy: n=12, segmental resection, or hemicolectomy: n=10, (sub)total colectomy: n= 13) after conservative treatment attempts in 32/35 (91.4%). The mean/median follow-up was 4.2/2.7 (range 0.1–17.0) years. The readmission rate for MC-associated symptoms was significantly higher after conservative treatment than after surgical therapy at 12 (0.84 vs. 0.36 per patient, p=0.036), 24 (1.00 vs. 0.52, p=0.048) and 36 (1.13 vs. 0.58, p=0.047) months, as was the number of patients with persistent laxative dependence (28/32 (87.5%) vs. 19/33 (57.6%); p = 0.007). Therapy-associated adverse events (Clavien-Dindo classification) were documented more often in surgically treated patients (11/35, 31.4%) (p=0.025). Conclusion Surgical treatment may be considered earlier if idiopathic or secondary MC or MR is correctly diagnosed, and conservative treatment has been attempted.

Dysphagia is a common symptom in patients presenting to the gastroenterologist. However, extraluminal causes of dysphagia may be missed by endoluminal diagnosis alone. This case report presents a 72-year-old man with slowly progressive dysphagia that occurred with the ingestion of certain solid foods and was intermittently associated with severe aspiration. Esophagogastroduodenoscopy and barium swallow study were both normal. However, a conventional x-ray and computed tomography (CT) scan of the neck revealed diffuse idiopathic skeletal hyperostosis (Forestier's disease) of the anterior cervical spine (C2-C7). Fiber endoscopic evaluation of swallowing (FEES) revealed functionally incomplete emptying of the oral cavity during swallowing, and the patient reported dysphagia score (EAT-10) was 23 (normal < 3). Surgical removal of the hyperostosis (C3-C6) resulted in immediate and sustained improvement in dysphagia at 3 months.

Abstract Background Patients with active nonvariceal upper gastrointestinal bleeding (NVUGIB) usually require urgent endoscopic treatment. Standard therapy (ST) using haemoclip + / − epinephrine injection is not always successful. Bipolar haemostatic forceps (HemoStat/Pentax®) are an approved medical device for the treatment of gastrointestinal bleeding. However, their use as a primary endoscopic treatment for active NVUGIB has not yet been proven in a randomized prospective study. Methods This is a prospective, randomized, multicentre superiority trial (n ≥ 5). Patients with active NVUGIB will be randomized (1:1) to ST and to experimental therapy (ET) by application of bipolar haemostatic forceps. In the case of failed initial treatment within 15 min, crossover treatment will be attempted first. Rescue treatment (e.g. via over-the-scope-clip) will then be allowed after 30 min. All patients will also receive standard therapy with proton pump inhibitors. Forty-five patients per treatment arm are required to demonstrate an absolute difference of 25.4% with a power of 80% and a significance level of 0.05. Discussion The hypothesis of the study is that bipolar haemostatic forceps are superior to ST in terms of successful primary haemostasis and the absence of recurrent bleeding within 30 days (combined endpoint). The 1:1 randomization is also ethically justifiable for this study, as both procedures are approved for the intervention in question. To further increase the safety of the patients in the study, crossover treatment and rescue treatment are planned. The prospective design seems feasible in a reasonable time frame (recruitment period of 12 months), as nonvariceal upper gastrointestinal bleeding is common. Anticoagulants and/or antiplatelet drugs could be an important confounding factor in the statistical analysis that needs to be taken into account and calculated if necessary. In conclusion, this randomized, prospective, multicentre study could make an important contribution to answering the question of whether bipolar haemostatic forceps could be the first-line therapy in the endoscopic treatment of stage Forrest I a + b NVUGIB. Trial registration ClinicalTrials.gov NCT05353062. Registered on April 30 2022.

This study developed an easy-to-use mortality prediction tool, which showed an acceptable discrimination and no significant lack of fit. The GeRi-Score was able to predict mortality and could distinguish between mild, moderate and high risk groups. Therefore, the GeRi-Score might have the potential to distribute the intensity of medical care. Several mortality-predicting tools for hip fracture patients are available, but all consist of a high number of variables, require a time-consuming evaluation and/or are difficult to calculate. The aim of this study was to develop and validate an easy-to-use score, which depends mostly on routine data. Patients from the Registry for Geriatric Trauma were divided into a development and a validation group. Logistic regression models were used to build a model for in-house mortality and to obtain a score. Candidate models were compared using Akaike information criteria (AIC) and likelihood ratio tests. The quality of the model was tested using the area under the curve (AUC) and the Hosmer–Lemeshow test. 38,570 patients were included, almost equal distributed to the development and to the validation dataset. The AUC was 0.727 (95% CI 0.711 – 0.742) for the final model, AIC resulted in a significant reduction in deviance compared to the basic model, and the Hosmer–Lemeshow test showed no significant lack of fit (p = 0.07). The GeRi-Score predicted an in-house mortality of 5.3% vs. 5.3% observed mortality in the development dataset and 5.4% vs. 5.7% in the validation dataset. The GeRi-Score was able to distinguish between mild, moderate and high risk groups. The GeRi-Score is an easy-to-use mortality-predicting tool with an acceptable discrimination and no significant lack of fit. The GeRi-Score might have the potential to distribute the intensity of perioperative medical care in hip fracture surgery and can be used in quality management programs as benchmark tool.

Zusammenfassung Einführung Die klinische Standardbehandlung des vestibulären Schwindels umfasst neben Medikamenten vor allem physikalische Therapie in Form von regelmäßigen Übungen. Vertidisan ist eine geplante digitale Gesundheitsanwendung (DiGA) zur strukturierten Schwindeltherapie. Ihr Inhalt ist multimodal und besteht unter anderem aus adaptiven Gleichgewichts-/Augenbewegungs- und visuellen Stimulationsübungen (Adaptive Balance and Eye Movements and Visual Stimulation, ABEV), von denen erwartet wird, dass sie durch neuronales Lernen eine antivertiginöse Wirkung haben. Methoden Es wurde eine Kohortenstudie mit 104 Patienten mit intraindividueller Kontrolle durchgeführt, um die klinische Wirksamkeit von 16 ABEV-Übungen für die Behandlung von peripheren Vestibulopathien isoliert zu untersuchen, wie sie auch in der geplanten DiGA Vertidisan zum Einsatz kommen. Unter Verwendung der Kurzversion vertigo symptom scale short form1 vertigo and related symptoms (VSS-sf1-VER) der schwindelspezifischen und validierten VSS-Ratingskala (Vertigo Symptom Scale) als primäre Ergebnisvariable wurden die Schwindelwerte vor der Therapie (Zeitpunkt T0) mit den entsprechenden Daten am Ende eines Zeitraums von 12–16 Wochen (Zeitpunkt T1) verglichen. Ergebnisse Von n=104 Patienten standen vollständige Datensätze zu T0 und T1 zur Verfügung. Der durchschnittliche VSS-sf1-V-Score verringerte sich von 3,80 (Median 4, Standardabweichung (SD) 0,47) auf 0,92 (Median 1, SD 1,19) von T0 bis T1 (Woche 12–16). Das Ergebnis ist statistisch signifikant (p=0,001) und weist eine hohe klinische Effektstärke auf. Schlussfolgerung Zusammenfassend ergibt die Analyse des Schwindel-Scores eine statistisch und klinisch signifikante Verringerung des Schwindels durch die Anwendung der 16 ABEV-Leitübungen.

BackgroundEndoscopic ultrasound-guided biliary drainage (EUS-BD) was associated with better clinical success and a lower rate of adverse events (AEs) than fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD) in recent single center studies with mainly retrospective design and small case numbers (< 50). The aim of this prospective European multicenter study is to compare both drainage procedures using ultrasound-guidance and primary metal stent implantation in patients with malignant distal bile duct obstruction (PUMa Trial).MethodsThe study is designed as a non-randomized, controlled, parallel group, non-inferiority trial. Each of the 16 study centers performs the procedure with the best local expertise (PTBD or EUS-BD). In PTBD, bile duct access is performed by ultrasound guidance. EUS-BD is performed as an endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade stenting (EUS-AGS). Insertion of a metal stent is intended in both procedures in the first session. Primary end point is technical success. Secondary end points are clinical success, duration pf procedure, AEs graded by severity, length of hospital stay, re-intervention rate and survival within 6 months. The target case number is 212 patients (12 calculated dropouts included).DiscussionThis study might help to clarify whether PTBD is non-inferior to EUS-BD concerning technical success, and whether one of both interventions is superior in terms of efficacy and safety in one or more secondary endpoints. Randomization is not provided as both procedures are rarely used after failed endoscopic biliary drainage and study centers usually prefer one of both procedures that they can perform best.Trial registrationClinicalTrials.gov ID: NCT03546049 (22.05.2018).

Background The recommended first-line treatment for unspecific and degenerative back pain consists of movement exercises and patient education. Objective Using a pragmatic, randomized controlled trial, we evaluated the effectiveness of a digital home exercise program on self-reported pain intensity compared with the standard of care for physiotherapy. Methods Participant recruitment was based on newspaper advertisements and a consecutive on-site assessment for eligibility and enrollment. Participants with unspecific and degenerative back pain aged ≥18 years were randomly assigned in a 1:1 ratio to receive a 12-week stand-alone digital home exercise program or physiotherapy. The digital home exercise program included 4 exercises daily, while physiotherapy included 6 to 12 sessions, depending on the severity of symptoms. The primary outcome was pain, which was assessed using a verbal numerical rating scale. The clinical relevance of pain reduction was assessed using the following thresholds: improvement of at least 1.4 points on the verbal numerical rating scale and a pain reduction of at least 30%. Results During the study period, 108 participants were assigned to the intervention group and 105 participants to the control group. The mean difference in pain scores between the 2 groups at 12 weeks was −2.44 (95% CI −2.92 to −1.95; P<.01) in favor of the intervention group. The group receiving the digital therapeutic achieved a clinically relevant reduction in pain over the course of the study (baseline vs 12 weeks), with a mean change of −3.35 (SD 2.05) score points or −53.1% (SD 29.5). By contrast, this change did not reach clinical relevance in the control group (mean −0.91, SD 1.5; −14.6%, SD 25.3). Retention rates of 89.9% in the intervention group and 97.3% in the control group were maintained throughout the study. Conclusions The use of the app-based home exercise program led to a significant and clinically relevant reduction in pain intensity throughout the 12-week duration of the program. The intervention studied showed superior improvement in self-reported pain intensity when compared with the standard of care. Given the great demand for standard physiotherapy for unspecific and degenerative back pain, digital therapeutics are evolving into a suitable therapeutic option that can overcome the limitations of access and availability of conventional modes of health care delivery into this spectrum of indications. However, further independent evaluations are required to support the growing body of evidence on the effectiveness of digital therapeutics in real-world care settings. Trial Registration German Clinical Trials Register DRKS00022781; https://tinyurl.com/hpdraa89

In hemosuccus pancreaticus,[1] potentially life-threatening bleeding into the pancreatic duct is usually caused by a large arterial pseudoaneurysm (average size of 52 mm) in chronic pancreatitis.[2] Bleeding from the papilla can be seen by endoscopy, and pseudoaneurysm can be detected by standard cross-sectional imaging. In this case report, a small pseudoaneurysm of the splenic artery with a fistula to the pancreatic duct could only be discovered by contrast-enhanced EUS (CE-EUS). A 54-year-old man with nonsteroidal anti-inflammatory drug intake and history of chronic alcohol pancreatitis was admitted for tarry stools. A cause for bleeding could not be identified by gastroscopy, ileocolonoscopy, abdominal ultrasound, and computed tomography [Figure 1]. However, the gastrointestinal bleeding continued. Small bowel video capsule endoscopy was performed and showed traces of blood in the duodenum. Repeated duodenoscopy presented a slight hemobilia from the papilla [Figure 2]. Therefore, hemosuccus pancreaticus was assumed, and CE-EUS indeed detected an arterial fistula to the pancreatic duct [Figure 3 and Video 1]. In the following, angiography showed a small pseudoaneurysm of the splenic artery [Figure 4], which was successfully treated by angiographic coiling [Figure 5] according to common guidelines.[3] Bleeding stopped after transfusion of summed up 9 units of blood. In some cases, EUS combined with Doppler ultrasound might be sufficient for the detection of the fistula[4] but failed in this patient. The useful application of CE-EUS in hemosuccus pancreaticus was previously shown in only one case report, in which the feeding vessel of a large pseudoaneurysm (42 mm) could not have been detected by angiography.[5] In conclusion, CE-EUS might be useful to detect hemosuccus pancreaticus due to small arterial pseudoaneurysms in patients with occult gastrointestinal bleeding.Figure 1: Computed tomography of the abdomen showing chronic pancreatitis with calcifications but cannot identify the source of gastrointestinal bleedingFigure 2: Slight hemobilia from the papilla is shown in repeated duodenoscopyFigure 3: Selected image from Video 1 showing the fistula from the arterial pseudoaneurysm to the pancreatic ductFigure 4: Selective angiography showing a small pseudoaneurysm (<20 mm) of the splenic artery. Fistula from the pseudoaneurysm to the pancreatic duct is not demonstratedFigure 5: Successfully treated pseudoaneurysm of the splenic artery by angiographic coiling. Direct application of the coils into the pseudoaneurysm had to be avoidedBRIEF DESCRIPTION CE-EUS was helpful to detect hemosuccus pancreaticus due to a small arterial pseudoaneurysm of the splenic artery in a patient with chronic pancreatitis and on-going occult gastrointestinal bleeding. Hemosuccus pancreaticus was successfully treated by angiographic coiling. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pancreatic cysts or dilated pancreatic ducts are often found by cross-sectional imaging, but only mucinous lesions can become malignant. Therefore, distinction between mucinous and non-mucinous lesions is crucial for adequate patient management. We performed a prospective study including targeted next generation sequencing (NGS) of cell-free DNA in the diagnostic endoscopic ultrasound (EUS)-guided workup. Pancreatic cyst(s) or main duct fluid obtained by EUS-guided FNA was analysed by carcinoembryonic antigen (CEA), cytology and deep targeted NGS of 14 known gastrointestinal cancer genes (AKT1, BRAF, CTNNB1, EGFR, ERBB2, FBXW7, GNAS, KRAS, MAP2K1, NRAS, PIK3CA, SMAD4, TP53, APC) with a limit of detection down to variant allele frequency of 0.01%. Results were correlated to histopathology and clinical follow-up. One hundred and thirteen patients with pancreatic cyst(s) and/or a dilated pancreatic main duct (≥5 mm) were screened. Sixty-six patients had to be excluded, mainly due to inoperability or small cyst size (≤10 mm). Forty-seven patients were enrolled for further analysis. A final diagnosis was available in 27 cases including 8 negative controls. In 43/47 (91.5%) of patients a KRAS- and/or GNAS-mutation was diagnosed by NGS. 27.0% of the KRAS-mutated and 10.0% of the GNAS-mutated lesions harbored multiple mutations. KRAS/GNAS-testing by NGS, cytology, and CEA had a sensitivity and specificity of 94.7/100%, 38.1/100%, and 42.1/75.0%, respectively. KRAS/GNAS-testing was significantly superior to CEA (P = .0209) and cytology (P = .0016). In conclusion, KRAS/GNAS-testing by deep targeted NGS is a suitable method to distinguish mucinous from non-mucinous pancreatic lesions, suggesting its usage as a single diagnostic test. Results must be confirmed in a larger cohort.

Preventive transhepatic tract embolisation (PTTE) after percutaneous biliary intervention (PBI) may reduce adverse events. The aim of this systematic review was to analyse feasibility, safety, and efficacy of PTTE with different embolic agents. A systematic literature research was performed according to the PRISMA guidelines. The identified studies were analysed concerning study quality, number of cases, indication, embolic agent, embolisation technique, success, and embolisation-related adverse events. Out of 62 identified records, 7 studies of mainly moderate study quality published through 2019 were included for further analysis. Cyanoacrylate (n = 4), gelatin sponge (n = 2), and coils (n = 1) were used as embolic agents in a total number of 314 patients. Technical success was 96–100%. Embolisation-related adverse events (glue migration, pain) occurred in 10/314 (3.2%) patients. Reduction of PBI-related pain was approved by one controlled study; haemorrhage events were reduced but not clearly significant. Overall, biliary leak, transhepatic bleeding, and PBI-related pain occurred in 7/201 (3.5%), 1/293 (0.3%), and 17/46 (36.9%) documented patients after PTTE. Adverse events which likely could not have been prevented by PTTE occurred in 23/180 (12.8%) patients. Embolic agents were not compared. In conclusion, PTTE is feasible and safe. It is effective concerning the prevention of PBI-related pain, and it may be effective concerning haemorrhage. Prevention of biliary leak is not proven. It remains unclear which embolic agent should be preferred. A prospective randomised trial including all preventable adverse events is lacking.

I would like to thank Dr Canakis and colleagues1Canakis A. Law R. Baron T. An updated review on ablative treatment of pancreatic cystic lesions.Gastrointest Endosc. 2020; 91: 520-526Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar for the comprehensive updated review on ablative treatment of pancreatic cyst lesions (PCLs) recently published in Gastrointestinal Endoscopy. The options, unanswered questions, and limitations of the previous pioneering studies were well summarized in the conclusions. However, I missed an explicit recommendation that ablative treatment of PCLs should be performed only within clinical trials. EUS-guided cyst ablation may be technically easy to conduct. However, current data from the quoted 16 studies may not be sufficient to recommend its general application. The real efficacy of ablative treatment can be proved only by studies with precise preinterventional diagnosis of the treated PCLs that are not mixed up with undefined cysts, particularly inasmuch as some of the undefined cysts are benign cysts,2Kimura W. Nagai H. Kuroda A. et al.Analysis of small cystic lesions of the pancreas.Int J Pancreatol. 1995; 18: 197-206Crossref PubMed Scopus (340) Google Scholar and the accuracy of preoperative diagnosis of PCLs by CT, MRI, or EUS reached only 61.4% to 80.5%.3Jang D.K. Song B.J. Ryu J.K. et al.Preoperative diagnosis of pancreatic cystic lesions: the accuracy of endoscopic ultrasound and cross-sectional imaging.Pancreas. 2015; 44: 1329-1333Crossref PubMed Scopus (32) Google Scholar Furthermore, serous cystadenoma, which has almost no risk for malign transformation,4Jais B. Rebours V. Malleo G. et al.Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas).Gut. 2016; 65: 305-312Crossref PubMed Scopus (205) Google Scholar and nonfunctional cystic pancreatic neuroendocrine tumors ≤2 cm,5Partelli S. Cirocchi R. Crippa S. et al.Systematic review of active surveillance versus surgical management of asymptomatic small non-functioning pancreatic neuroendocrine neoplasms.Br J Surg. 2017; 104: 34-41Crossref PubMed Scopus (109) Google Scholar which have a predominately benign nature, may be better candidates for active surveillance than for ablative treatment. The introduction argued against preventive surgery on the grounds that the incidence of malignancy is relatively low in branch-duct intraductal papillary mucinous neoplasms,6Oyama H. Tada M. Takagi K. et al.Long-term risk of malignancy in branch-duct intraductal papillary mucinous neoplasms.Gastroenterology. 2020; 158: 226-237.e5Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar which is likely the most prevalent cyst entity. However, this argument can also be used against preventive ablative treatment, particularly ablative treatment by ethanol, chemotherapeutic agents, or radiofrequency ablation because these treatments show an adverse event rate from 10% to 21%, including pancreatitis, pancreatic duct stenosis, or perforation. Therefore, ablative treatment must also demonstrate reduced disease-related mortality in comparison with active surveillance.7Choi J.H. Lee S.H. Choi Y.H. et al.Clinical outcomes of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions compared with the natural course: a propensity score matching analysis.Therap Adv Gastroenterol. Epub 2018 Mar 7; Crossref PubMed Scopus (14) Google Scholar Because this can be proved only by long-term studies, most of the previous studies used cyst resolution as a surrogate parameter for successful treatment. However, cyst resolution in imaging methods does not necessarily correlate with histologically proven cyst resolution, which was shown in one of the quoted studies.8Oh H.C. Seo D.W. Song T.J. et al.Endoscopic ultrasonography-guided ethanol lavage with paclitaxel injection treats patients with pancreatic cysts.Gastroenterology. 2011; 140: 172-179Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Therefore, and owing to unknown late side effects of ablative treatment, long-term surveillance after endoscopic therapy should still be mandatory. The author disclosed no financial relationships. An updated review on ablative treatment of pancreatic cystic lesionsGastrointestinal EndoscopyVol. 91Issue 3PreviewPancreatic cysts are common and often incidentally detected on abdominal imaging. Their prevalence in asymptomatic individuals depends on the screening modality used. The incidence of these lesions increases with age and may be detected in nearly half of elderly patients undergoing high-resolution magnetic resonance imaging. Some, but not all, pancreas cysts have malignant potential. The overall risk is small but induces significant anxiety for the patient. When determining management options, it is important to consider the patient’s age, medical comorbidities, and surgical risks as well as the wishes of the patient. Full-Text PDF

We describe the case of a 71-year-old woman who presented with obstructive jaundice and subhilar bile duct stenosis. MRI showed extensive cholecystolithiasis with an impacted bile stone in the cystic duct suggesting Mirizzi syndrome. Delayed enhancement of the thickened gallbladder wall suggested inflammation instead of carcinoma. After drainage of the obstructed bile duct via ERCP, the patient developed liver abscesses with a nosocomial vancomycin-resistant enterococcus infection treated by linezolid. After 4 weeks, the VRE infection was complicated by a new-onset 23 rRNA gene-mediated linezolid resistance in the same bacterial strain, which was proven via core genome multilocus sequencing. Meropenem and tigecycline were administered according to a resistogram. Furthermore, percutaneous transhepatic biliary drainage of both sides of the liver was necessary. After demission, the patient had to be admitted again due to septic shock. An emergency operation revealed extended, inoperable gallbladder cancer. The patient died a few days later in the intensive care unit. An earlier diagnosis of bile duct infiltrating gallbladder cancer by cholangioscopy or laparoscopy and treatment of vancomycin-resistant enterococcus infection with daptomycin may have changed the clinical course of the disease.