Same-session endoscopic diagnosis and symptom palliation in pancreato-biliary malignancies: Clinical impact of rapid on-site evaluation (ROSE)

Abstract

Introduction: Besides increasing adequacy, Rapid-on-Site Evaluation (ROSE) during Endoscopic Ultrasound (EUS) or Endoscopic Retrograde Cholangiopancreatography (ERCP) may impact on choices and timing of subsequent therapeutic procedures, yet unexplored. Methods: This was a retrospective evaluation of a prospectively maintained database of a tertiary, academic centre with availability of ROSE and hybrid EUS-ERCP suites. All consecutive patients referred for pathological confirmation of suspected malignancy and Jaundice or Gastric Outlet Obstruction (GOO) between Jan-2020 and Sep-2022 were included. Results: Of 541 patients with underlying malignancy, 323 (59.7%) required same-session pathological diagnosis (male: 54.8%; age 70 [Interquartile Range 63-78]; pancreatic cancer: 76.8%, biliary tract adenocarcinoma 16.1%). ROSE adequacy was 96.6%, higher for EUS versus ERCP. Amongst 302 patients with Jaundice, ERCP-guided stenting was successful in 83.1%, but final drainage was completed in 97.4% thanks to 43 EUS-guided Biliary Drainages. 21 patients with GOO were treated with 15 EUS-Gastro-Enterostomies and 6 duodenal stenting. All 58 therapeutic EUS procedures occurred after adequate ROSE. Amongst ERCP-guided placement of stents, the use of plastic stents was significantly higher amongst patients with inadequate ROSE (10/11 [90.9%] versus adequate sampling (14/240 [5.8%], p <0.0001, OR=161 [95%CI 19-1352]). Median hospital stay for diagnosis and palliation was 3 [2-7] days and median time to chemotherapy was 33 [24-47] days. Conclusions: Nearly two-thirds of oncological candidates to endoscopic palliation require contemporary pathological diagnosis. ROSE adequacy allows, since the index procedure, state-of-the-art therapeutics standardly restricted to pathologically confirmed malignancies (e.g. uncovered SEMS or therapeutic EUS), potentially reducing hospitalization and time to oncological treatments.