Background EUS-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed ERCP is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. Methods Consecutive duct access procedures (n=2205; 95% biliary) performed between June 2013-November 2015 at a tertiary-care center were reviewed. ERCP was used first-line, EUS-DAD as salvage of ERCP, and PTBD when both failed. Procedures were defined as index in patients without prior endoscopic duct access and combined when EUS-DAD followed successful ERCP. The main outcomes were EUS-DAD and PTBD rates. Results EUS-DAD was performed overall in 7.7% (170/2205), 9.1% (116/1274) index and 5.8% (54/931) follow-up procedures. Most index EUS-DADs were performed following (46%) or anticipating (39%) ERCP failure, whereas 15% followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically-altered anatomy (58.2% [39/67)] vs. 6.4% [77/1207]). PTBD was required in 0.2% (3/1274). Among follow-up procedures, ERCP represented 85.7%, cholangio-pancreatography through mature transmural fistulas 8.5% and EUS-DAD 5.8%. No patient required PTBD. The secondary PTBD rate was 0.1% (3/2205). Six primary PTBDs were performed (0.4% [9/2211] overall PTBD rate). Conclusions EUS-DAD was required in 7.7% of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1%. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes ERCP limitations precluding primary and salvage PTBD in most cases.

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells is a rare tumour that has been published under a wide variety of names, including pleomorphic carcinoma, giant cell carcinoma, sarcomatoid carcinoma and carcinosarcoma, among others. For these reasons and its low frequency, the reports of these tumours are scarce and frequently lead to confusion with other entities which present with giant cells. We present the case of a patient with obstructive jaundice and a mixed cystic and solid pancreatic mass, accompanied by multiple hepatic lesions. The histological study of the material obtained by endoscopic ultrasound guided biopsy demonstrated a proliferation of atypical epithelioid cells, accompanied by a spindle cell component with marked pleomorphism and numerous osteoclast-like giant cells. The epithelioid component showed positive immunostaining with cytokeratin cocktail and cytokeratin 7. The spindle cell component showed coexpression of cytokeratins and vimentin. The osteoclast-like giant cells were positive for CD68. Protein p53 was overexpressed in both epithelial and spindle cell neoplastic components, and was negative in the giant cells. These findings permitted the diagnosis of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells. This case outlines the effectiveness of endoscopic ultrasound-guided biopsy and the importance of morphological and immunohistochemical examination in the diagnosis of different types of pancreatic tumours, especially when they are in advanced stages and are not suitable for surgical treatment.

BACKGROUND: Endoscopic mucosal resection is one of the most frequent therapeutic alternatives for large colorectal lateral spreading tumors. There are few data on the prevalence of synchronous lesions on these patients. OBJECTIVE: To describe the prevalence of synchronous colorectal lesions in patients referred for endoscopic mucosal resection of lateral spreading tumors >20 mm. METHODS: We reviewed the endoscopic database of our Department and identified adult patients who were referred for the resection of a colorectal lateral spreading tumor >20 mm and had a diagnostic colonoscopy performed up to six months before. The proportion of patients with at least one synchronous lesion was estimated. The following features were compared between patients with and without synchronous lesions: age, gender, bowel preparation quality and cecal intubation on index colonoscopy and therapeutic colonoscopy, serrated adenoma as index lesion. RESULTS: From December 2016 to November 2017, we identified 70 patients who fulfilled inclusion criteria. Median size of lesions was 25 mm (20-45). Eighty percent were located in the right colon and 35.71% were serrated adenomas. Synchronous lesion rate was 38.57%. Bowel preparation quality was similar in both groups when comparing both index and therapeutic colonoscopies. Patients with synchronous lesions had a higher proportion of serrated adenoma as index lesion than patients without synchronous lesions [51.85% vs 25.58%, OR 3.13 (1.13-8.68), P=0.03]. CONCLUSION: We found a high prevalence of synchronous lesions among patients with a large colorectal lateral spreading tumor. This risk seems to be increased if index lesions are serrated adenomas.

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