Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) has emerged over the last years as an alternative procedure to percutaneous drainage (PT)‐GBD in patients with acute cholecystitis (AC) at high surgical risk. This process has been driven by the advent of lumen‐apposing metal stents (LAMS) with electrocautery‐enhanced capability, which has rendered the drainage procedure easier to accomplish and safer. Studies and meta‐analyses have proven the superiority of EUS‐GBD over PT‐GBD in high‐surgical‐risk patients with AC. Little evidence exists in the same setting that EUS‐GBD compares equally with laparoscopic cholecystectomy (LC). Moreover, EUS‐GBD might theoretically have a possible role in patients at high surgical risk with an indication to undergo cholecystectomy or with a high probability of conversion from LC to open cholecystectomy. Properly designed studies are needed to better clarify the role of EUS‐GBD in these patient populations.
A 41-year-old man with acute pancreatitis of unknown etiology developed a 17 × 8-cm walled-off necrosis (WON) that was drained percutaneously. The purulent fluid grew Klebsiella and Candida albicans. After transfer to our hospital, endoscopic ultrasound (EUS)-guided drainage was performed, and a 20 × 10-mm Axios stent was placed. The solid component
We read with great interest the retrospective study by Marx et al. 1 reporting endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) treatment in 27 patients with sporadic, G1, nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) (mean lesion size 14 AE 4.6 mm). There was a 93% complete response, with three cases of severe acute pancreatitis (11.1%), which evolved into a pancreatic fluid collection requiring EUS-guided drainage. These patients had lesion diameter of 10, 10, and 9 mm and an age ranging from 58 to 66. 1 Was performance of EUS-RFA indicated in these patients? The European Neuroendocrine Tumor Society guidelines recommends surveillance in patients with lesions <20 mm. However, the level of evidence beyond this conclusion is extremely low. 2 Conversely, in surgical series, about 30% of small NF-pNETs are operated, with serious adverse events (AEs) in 18-32% of cases. 3,4 EUS-RFA has been proposed as a minimally invasive alternative to surgery. When a new therapeutic modality is introduced, proper patient selection is critical in order to preserve your gun from a rapid and irreversible failure. In our opinion, this was not the case in the paper by Marx et al., 1 where grade III AEs ocurred in NF-pNETs ≤10 mm, which may never ever grow up and in which control of RFA current dispersion might be difficult, also if the smallest 5 mm needle was utilized, as we assume.A recent systematic review has reported 93% effectiveness and no major AEs (mean lesion size 16 mm). 5 If this is the case, we believe we should keep shooting EUS-RFA for small selected NF-pNETs, with size ranging from 14-15 to 20 mm, especially those located in the pancreatic head, while balancing other patient and lesion variables. 2 With this in mind, these patients should be offered EUS-RFA, surveillance and surgery to make them able to take their most appropriate personal decision.
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