EP may be curative for patients with AC limited to the duodenal mucosa or the sphincter of Oddi without lymphovascular invasion. Due to the presence of more invasive stages at diagnosis, EP may not be curative for ACs of the biliopancreatic subtype. The significance of tumour size is limited by other confounders, such as the histological subtype.

EUS-BD is technically feasible in patients with ascites. Our results suggest that EUS-BD may be a clinically effective and safe alternative after failed ERCP in patients with ascites.

Background: The differential diagnosis between mucinous(M) and non-mucinous (NM) pancreatic cystic lesions (PCLs) is often difficult and both false positive and negative results can lead to clinically relevant overtreatment and undertreatment. Dosage of intracystic Carcinoembryonic antigen (CEA) with a cut-off>192 ng/ml suggests the diagnosis of M-PCL, but its sensitivity is limited. Recently, it has been reported that low levels of intracystic glucose diagnose M-PCLs with high accuracy, but data are limited and heterogeneous. Objective: We aimed to perform a metaanalysis to gather data on sensitivity, specificity and accuracy of intracystic glucose as compared with CEA for the diagnosis of M-PCLs. Methods: A computerized bibliographic search was performed on Pubmed. Pooled effects were calculated using a random-effects model and expressed in terms of pooled sensitivity and specificity and OR (95% CI) for accuracy for the diagnosis of M-PCLs. Heterogeneity was evaluated by I 2 and publication bias by Begg-Mazumdar test and funnel plot visual inspection. Results: Overall, 4 cohort studies were included (3 conducted in the US, 1 in Portugal), for a total of 319 patients (207 M, 112 NM). The cut-off employed for glucose were 50 in 3 studies and 66 mg/dl in one, while all studies employed the CEA cut-off of 192 ng/ml. The employed gold-standard for diagnosis in the 4 studies was a composite of surgical pathology and cytology. Dosage of glucose showed a higher pooled sensitivity and lower heterogeneity (92%; I 2 Z 0%) compared to CEA (69.4%; I 2 Z64%), while specificity was higher for CEA (75.6% glucose vs 92% CEA) with lower heterogeneity (I 2 Z89% glucose vs 69% CEA). Dosage of glucose was very close to be significantly superior in terms of pooled accuracy (OR 1.96; 95% CI 0.97-3.94; pZ0.057; I 2 Z53%). There was no publication bias at Begg-Mazumdar test and funnel plot. Conclusion: Our meta-analysis suggests that intracystic dosage of glucose is more sensitive, but CEA more specific for the diagnosis of mucinous PCLs, with an overall better accuracy of glucose. Given the heterogeneity of the results and the relative low number of investigated patients considering the high prevalence of PCLs, more studies are needed to define if combined use of both markers with different cut-offs is needed to increase accuracy significantly.

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The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy. We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.

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