Background and study aims:Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a nonsurgical treatment option for managing pancreatic lesions. We sought to evaluate the safety and efficacy of EUS-RFA for large (≥4 cm) branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Patients and methods:Patients with a definitive diagnosis of BD-IPMN who declined or were unfit for surgery underwent EUS-RFA in a single-arm prospective trial. Ablation was performed using a 19G EUS-RFA needle. RFA applications were delivered up to a maximum threshold of 45 seconds or 400 ohms impedance. Safety was assessed using AGREE guidelines. Potential for efficacy was assessed using cyst volume and cyst fluid KRAS GNAS mutations using next-generation sequencing (NGS). Adverse events (AEs) were analyzed per RFA session, while response was analyzed per BD-IPMN. Results:Thirty BD-IPMNs (mean diameter 4.6 ± 1.7 cm; 80% multilocular) in 25 participants (mean age 74.1 ± 8.3 years) underwent 41 EUS-RFA sessions. AEs occurred in 12.2% of procedures (5/41), the majority being AGREE Grade 3A (9.8%, 4/41). During a mean follow-up of 18 ± 5 months, 22 of 28 BD-IPMNs (78.6%) achieved ≥ 50% reduction in cyst volume, and 11 (39.3%) demonstrated complete (≥90%) response. Among 26 BD-IPMNs that revealed KRAS GNAS mutations, follow-up NGS was performed in 17, with 88.2% showing loss of detectable mutations. Conclusions:EUS-RFA in large, predominantly multilocular BD-IPMNs shows promising volumetric efficacy. Safety may be improved through refined energy delivery and technical advances. Molecular response remains exploratory and requires further validation. Long-term studies assessing progression-free outcomes are needed to define its role as an organ-preserving therapeutic option.

Background and Aims:Non-gastric subtype of branch duct (BD)-intraductal papillary mucinous neoplasms (IPMNs) are associated with high-grade dysplasia/invasive adenocarcinoma (HGD/IC) and disease progression. We evaluated preoperative prediction of gastric vs. non-gastric BD-IPMN subtypes and assessed a needle-based confocal laser endomicroscopy-guided artificial intelligence algorithm (nCLE-AI) for detecting HGD/IC in pathologist-reclassified BD-IPMNs. Methods:Participants with resected BD-IPMNs were enrolled from prospective studies (2015-2024). Phase 1: lesions were reclassified by subtype and dysplasia grade through blinded pathologist review, with discordant cases receiving MUC immunostaining and consensus review. Phase 2: using this reclassified pathology data, preoperative clinical and morphological features were analyzed to predict BD-IPMN subtypes. Phase 3: nCLE-AI performance in detecting HGD/IC within reclassified gastric and non-gastric BD-IPMNs was evaluated using preoperative endomicroscopy videos. Results:Among 63 resected BD-IPMNs (mean diameter=35.0±10.1 mm), 38% were classified as HGD/IC. Phase 1: The interobserver agreement among pathologists for subtype classification was moderate (k=0.52; 95%CI: 0.27-0.77). Phase 2: Multivariable analysis or preoperative variables revealed Kyoto high-risk stigmata (aOR=11.568, p=0.007), unifocal lesions (aOR=8.354, p=0.041), and lower BMI (aOR=1.37, p=0.04) predicted non-gastric subtype. Phase 3: The nCLE-AI algorithm using presurgical endomicroscopy imaging showed comparable sensitivity for detecting HGD/IC in non-gastric and gastric IPMN subtypes (83% vs. 82%, p=0.92), but significantly higher specificity (100% vs. 44%, p=0.06) and accuracy (87% vs. 53%, p<0.02) in the non-gastric subtype. Conclusion:Moderate interobserver variability in BD-IPMN subtype classification among pathologists highlights the need for immunohistochemistry and consensus review in challenging cases. Preoperative clinical variables can predict non-gastric subtype which is associated with less favorable prognosis. nCLE-AI shows improved performance in detecting HGD/IC in non-gastric BD-IPMNs, where accurate risk stratification is particularly important due to higher risk of progression.

BACKGROUND:The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in managing uncomplicated acute biliary pancreatitis (ABP) remains unclear. This population-based study assessed the impact of ERCP timing on outcomes in hospitalized ABP patients without cholangitis or sepsis. METHODS:Using the Nationwide Readmission Database (2016 to 2020), patients with ABP who underwent ERCP were identified, excluding those with cholangitis/sepsis. ERCP timing was categorized as early (0 to 1 d) or delayed (2 to 7 d). Outcomes, including mortality, 30-day readmissions, and health care resource utilization were analyzed using multivariable logistic regression. RESULTS:Among 54,250 noninfectious ABP patients, 42.13% underwent ERCP. There was no significant difference in in-hospital mortality between early and delayed ERCP groups (0.26% vs. 0.24%, P =0.73). However, 30-day readmission rates rose with each day of delay in the delayed ERCP group ( P <0.001) and were higher overall (8.26% vs. 7.51%, P =0.03). Delayed ERCP was associated with increased 30-day readmissions (OR: 1.11, 95% CI: 1.00-1.22); using alternate categorical thresholds, ERCP on day 4 or later was also linked to higher odds of readmission (OR: 1.35, 95% CI: 1.18-1.54). Early ERCP was associated with reduced mean length of stay by 1.51 days (95% CI: -1.51 to -1.50; P <0.001) and hospital costs by $1536.45 (95% CI: -$1545.37 to -$1527.52; P <0.001) after multivariable adjustment. Compared with day 4 or later, ERCP on days 2 to 3 further reduced stay by 2.42 days and costs by $3756.95 (both P <0.001). CONCLUSION:Delayed ERCP was associated with increased 30-day readmission rates and greater health care resource utilization and ERCP performed within 4 days may improve hospital quality metrics in patients with noninfectious acute biliary pancreatitis.

Advancements in endoscopic ultrasound-guided tissue acquisition (EUS-TA) for solid pancreatic masses have prompted updates in society guideline recommendations. However, the extent to which these recommendations have been adopted in clinical practice remains unclear. Thus, we sought to characterize current practice patterns and beliefs regarding EUS-TA for solid pancreatic masses in a large, international cohort of endosonographers. We developed and distributed an electronic survey to 1,281 endosonographers worldwide between September and November 2024. The survey aimed to evaluate EUS-TA practices across six domains: A) needle selection, B) sampling technique, C) method guiding the number of passes, D) specimen handling, E) quality indicator (QI) monitoring, and F) factors influencing decision-making. The response rate was 30

Cavernous transformation of the portal vein is a rare condition that is often misdiagnosed or diagnosed late due to its insidious onset and nonspecific clinical presentation. It is most often associated with prothrombotic conditions, liver disease, malignancy, or local inflammation. We report a rare case involving a 65‑year‑old woman with HIV infection (CD4 count 96 cells/µL) who developed portal vein cavernous transformation leading to obstructive biliopathy. Cholangioscopy excluded intrinsic mucosal pathology or neoplasm, and additional testing ruled out other hypercoagulable disorders. Following placement of a biliary stent, her cholestatic symptoms resolved and her alkaline phosphatase and bilirubin levels declined. This case highlights HIV as an unusual precipitant of portal vein cavernous transformation and discusses imaging findings, underlying etiologies, and other management options.

BACKGROUND AND AIMS:EUS-guided gallbladder drainage (EUS-GBD) has been found to be a safe and effective treatment option for patients with cholecystitis. There are limited data regarding the use of EUS-GBD in patients with symptomatic cholelithiasis without cholecystitis. Therefore, the aim of this study was to examine the safety and efficacy of EUS-GBD for the management of gallstones in nonoperative candidates without cholecystitis. METHODS:This 2-center retrospective study examined patients with symptomatic cholelithiasis without cholecystitis treated with EUS-GBD via lumen-apposing metal stent (LAMS) placement who were deemed nonsurgical candidates. The primary outcome was complete gallstone clearance, and secondary outcomes included clinical success, technical success of LAMS placement, and adverse events. RESULTS:A total of 23 patients received EUS-GBD for symptomatic cholelithiasis in the absence of cholecystitis. LAMSs were successfully placed in all patients (technical success rate, 100%). Lithotripsy was performed in 9% of patients, and complete stone clearance was achieved in 100% of patients (87% achieved clearance within 1 treatment). Sixteen (70%) patients underwent follow-up endoscopy, during which 1 patient was noted to have small residual diminutive stones on cholecystoscopy via the LAMS. Interval imaging in all patients who did not undergo follow-up endoscopy revealed stone clearance and decompression of the gallbladder. There were no procedure-related adverse events noted, and no recurrence of symptoms was reported over a mean follow-up period of 9 months. CONCLUSIONS:This 2-center case series provides preliminary evidence that EUS-GBD may offer a safe and effective method for treating symptomatic cholelithiasis without cholecystitis in nonoperative candidates.