Reply to Firkins and Krishna

We would like to thank Dr. Firkins and Dr. Krishna for their interest and comments on our recent publication “Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts” [1]. Our study is the second prospective study evaluating this novel method and the first one to report a procedure-associated fatality. Although it is well known that the adverse event rate tends to be underreported in retrospective studies, the observed fatality was unexpected and the case will be further described in this reply.

The patient was an 85-year old man, treated for hypertension, but otherwise healthy. He was referred for endoscopic ultrasound evaluation of a mixed-type intraductal papillary mucinous neoplasm (IPMN) with mural nodules and pancreatic duct dilatation, which was diagnosed following several episodes of mild pancreatitis. The procedure was uneventful with a total procedure time of 22 minutes; however, the cyst fluid was excessively viscous and the cyst content could therefore not be completely evacuated. Four microbiopsies were obtained. The patient developed pancreatitis despite perioperative hydration and administration of rectal nonsteroidal anti-inflammatory drugs. During the course of hospitalization, the patient developed respiratory and kidney failure and was transferred to the intensive care unit. Computed tomography scan of the abdomen revealed partial pancreatic necrosis and severe peripancreatic edema, but no organized fluid collections. As there was no change in the patient’s condition, the treatment was discontinued on day 15.

As for the second comment, severity of adverse events was defined using the widely accepted terminology for endoscopic adverse events [2]. Connection with the pancreatic duct (e. g. in IPMNs) might, at least in theory, lead to an increased risk of post-procedural pancreatitis. Although we did not observe any adverse events following biopsy of serous cysts, the presence of IPMN epithelium in biopsy material was not a statistically significant predictor of adverse events in this study (see Table 4 in our paper [1]).

Publication History

Received: 13 September 2020

Accepted: 23 September 2020

Article published online:
17 December 2020

• References

• 1 Kovacevic B, Klausen P, Rift CV. et al. Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts. Endoscopy 2020; DOI: 10.1055/a-1214-6043.
• 2 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454