Portal de Periódicos da CAPES

EUS-guided fine needle aspiration of pancreatic cysts: A retrospective analysis of complications and their predictors

2005; Elsevier BV; Volume: 3; Issue: 3 Linguagem: Inglês

10.1016/s1542-3565(04)00618-4

1542-7714

Li‐Na Lee, John R. Saltzman, Brenna C. Bounds, John M. Poneros, W BRUGGE, Paul M. Thompson,

Gastrointestinal disorders and treatments

Background & aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) of pancreatic cysts is considered safe, however, data are conflicting regarding complication rates. The aim of this study was to determine the complication rate of EUS-guided pancreatic cyst aspiration and predictors of these complications. Methods: Results of pancreatic cyst EUS FNA at 2 academic institutions from March 1996 to October 2003 were reviewed. A total of 603 patients with 651 pancreatic cysts were evaluated. Complications were identified from clinic, emergency department, and discharge notes, and laboratory and radiologic data. Data collected were as follows: cyst size, location, septations, diagnosis, number of passes, needle size, status as inpatient or outpatient, performance of same-day endoscopic retrograde cholangiopancreatography (ERCP), and use of prophylactic antibiotics. Results: Complications were identified in 13 patients (2.2%, 13 of 603): 6 patients had pancreatitis, 4 patients had abdominal pain, 1 patient had a retroperitoneal bleed, 1 patient had an infection, and 1 patient had bradycardia. Twelve patients required hospitalization, with an average length of stay of 3.8 ± 1.1 days. Type of cyst, size, presence of septations or mass, and same-day ERCP were not predictors of complications. Conclusions: EUS-guided pancreatic cyst aspiration carries a low complication rate similar to that reported for solid pancreatic lesions. No patient or cyst characteristics appear to be predictive of adverse events. Background & aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) of pancreatic cysts is considered safe, however, data are conflicting regarding complication rates. The aim of this study was to determine the complication rate of EUS-guided pancreatic cyst aspiration and predictors of these complications. Methods: Results of pancreatic cyst EUS FNA at 2 academic institutions from March 1996 to October 2003 were reviewed. A total of 603 patients with 651 pancreatic cysts were evaluated. Complications were identified from clinic, emergency department, and discharge notes, and laboratory and radiologic data. Data collected were as follows: cyst size, location, septations, diagnosis, number of passes, needle size, status as inpatient or outpatient, performance of same-day endoscopic retrograde cholangiopancreatography (ERCP), and use of prophylactic antibiotics. Results: Complications were identified in 13 patients (2.2%, 13 of 603): 6 patients had pancreatitis, 4 patients had abdominal pain, 1 patient had a retroperitoneal bleed, 1 patient had an infection, and 1 patient had bradycardia. Twelve patients required hospitalization, with an average length of stay of 3.8 ± 1.1 days. Type of cyst, size, presence of septations or mass, and same-day ERCP were not predictors of complications. Conclusions: EUS-guided pancreatic cyst aspiration carries a low complication rate similar to that reported for solid pancreatic lesions. No patient or cyst characteristics appear to be predictive of adverse events. Over the past decade abdominal imaging studies have improved in quality and are used more frequently. With this development the discovery of pancreatic cystic lesions has become more common. These lesions are often of unclear clinical significance and pose a diagnostic dilemma. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) has expanded tremendously in recent years and new tissue-handling techniques hold promise to improve diagnostic yield. EUS FNA has been used to diagnose the type of cyst as well as to guide management decisions,1Sedlack R. Affi A. Vazquez-Sequeiros E. et al.Utility of EUS in the evaluation of cystic pancreatic lesions.Gastrointest Endosc. 2002; 56: 543-547Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar, 2Hernandez L.V. Mishra G. Forsmark C. et al.Role of EUS and EUS-guided fine needle aspiration in the diagnosis and treatment of cystic lesions of the pancreas.Pancreas. 2002; 25: 222-228Crossref PubMed Scopus (108) Google Scholar, 3Frossard J.L. Amouyal P. Amouyal G. et al.Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions.Am J Gastroenterol. 2003; 98: 1516-1524Crossref PubMed Scopus (347) Google Scholar, 4Wiersema M.J. Vilmann P. Giovannini M. et al.Endosonography-guided fine-needle aspiration biopsy diagnostic accuracy and complication assessment.Gastroenterology. 1997; 112: 1087-1095Abstract Full Text PDF PubMed Scopus (1104) Google Scholar, 5Eloubeidi M.A. Chen V.K. Eltoum I.A. et al.Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer diagnostic accuracy and acute 30-day complications.Am J Gastroenterol. 2003; 98: 2663-2668PubMed Google Scholar, 6Harewood G.C. Wiersema M.J. Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses.Am J Gastroenterol. 2002; 97: 1386-1391Crossref PubMed Google Scholar, 7Chang K.J. Nguyen P. Erickson R.A. et al.The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma.Gastrointest Endosc. 1997; 45: 387-393Abstract Full Text Full Text PDF PubMed Scopus (544) Google Scholar however, there are few outcomes studies on this procedure to date. EUS FNA of cystic lesions has been reported to have a higher complication rate than that of solid lesions. In a study from 1997 with 22 cystic lesions, the complication rate for EUS FNA of cystic lesions was high at 14%.4Wiersema M.J. Vilmann P. Giovannini M. et al.Endosonography-guided fine-needle aspiration biopsy diagnostic accuracy and complication assessment.Gastroenterology. 1997; 112: 1087-1095Abstract Full Text PDF PubMed Scopus (1104) Google Scholar A more recent study with 114 pancreatic cysts suggested a lower complication rate of 3.5% for EUS FNA of these lesions.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar Because incidental pancreatic cystic lesions are identified more frequently on routine computed tomography scans, EUS FNA of these lesions will be performed more commonly. The aim of this study was to determine the complication rate of EUS-guided aspiration of pancreatic cystic lesions and to identify predictors of these complications. From March 1996 to October 2003, 603 patients underwent EUS FNA of 651 pancreatic cystic lesions. The procedures were performed in 2 academic centers by 4 experienced endosonographers. We retrospectively reviewed these procedures. The study protocol was approved by the Human Research Committee of the Partners Healthcare System. The endoscopic databases from both hospitals and the institution-wide research database, constructed from the International Classification of Diseases, 9th edition, and CPT-11 (current procedural terminology) codes, were used to identify all EUS FNA of pancreatic cystic lesions. Aspirations of peripancreatic cystic lesions were excluded. Endoscopy notes were reviewed to gather data including cyst size, location, presence of septations, number of passes, needle size, patient status as inpatient or outpatient, performance of same-day endoscopic retrograde cholangiopancreatography (ERCP), and use of prophylactic antibiotics. Data on complications were collected by performing a complete medical records review as addressed later. Results of available cytology and pathology also were noted. Patients were placed in the left lateral decubitus position and conscious sedation with intravenous midazolam, fentanyl, meperidine, and/or droperidol was used in all patients undergoing EUS FNA according to the judgment of the endoscopist. Antibiotic prophylaxis was administered at the discretion of each endosonographer and included fluoroquinolones, ampicillin, vancomycin, and gentamicin. A fluoroquinolone given for 3 days after the procedure was the most common form of prophylaxis. For large or complex cysts that were drained incompletely, a one-time dose of intravenous ampicillin and gentamicin often was administered during the procedure. Endosonography was performed at each institution using a curvilinear echoendoscope (Olympus GF-UC30P, GF-UCT 140-AL5; Olympus America Inc., Melville, NY, or Pentax EG3630U; Pentax Medical Company, Montvale, NJ) for the majority of cases. The processors used included Aloka SSD-5000-OLY and Dornier MedTech (Olympus) with the Olympus echoendoscopes and Hitachi EUB 525 and Hitachi EUB 6000 (Hitachi Medical Systems America, Inc., Twinsburg, OH) with the Pentax linear array system. Each of the linear echoendoscopes are modified oblique forward-viewing instruments with curved linear ultrasound transducers that provide real-time visualization of the aspiration needle. Lesions in the head of the pancreas were approached transduodenally whereas body and tail lesions were targeted using a transgastric approach. Doppler imaging was used to avoid intervening vessels. After localizing the target lesion, aspiration was performed using 19-gauge to 25-gauge adjustable needles (EUSN-1 Echotip; Wilson-Cook Medical, Inc, Winston-Salem, NC; or Sonotip II; Mediglobe Corporation, Tempe, AZ). The needle system was inserted through the working channel of the echoendoscope and the needle was advanced through the bowel wall under ultrasonographic guidance into the lesion. Once the needle was positioned in the lesion, the stylet was removed and vacuum suction was applied with a 10-cc syringe attached to the handle of the needle system. Fluid aspirates were obtained by gently moving the needle back and forth through the lesion until no further fluid was obtained. The needle then was retracted and the needle and handle were removed. Aspirates were sent in an empty container for analysis (carcinoembryonic antigen and amylase) and either sprayed onto slides or placed into Cytolyt preservative (Cytyc, Boxborough, MA) for cytologic evaluation. After EUS FNA, all patients at both hospitals were observed in the recovery area for 1–2 hours and then given liquids to drink before discharge. They were contacted 1–2 weeks after the procedure to discuss the cytology results. Complications were defined as any unexpected event occurring during or after the procedure causing morbidity.9American Society for Gastrointestinal EndoscopyQuality assessment of endoscopic ultrasound.Gastrointest Endosc. 2002; 55: 798-801Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Immediate complications occurred during the procedure or before discharge from the endoscopy unit; early complications occurred up to 30 days after the procedure.10Cotton P.B. Outcomes of endoscopy procedures struggling towards definitions.Gastrointest Endosc. 1994; 40: 514-518Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar Late complications arose more than 30 days after the procedure. The severity of complications was defined based on length of hospitalization with mild consisting of ≤3 nights, moderate consisting of 4–10 nights, and severe consisting of >10 nights or requiring intensive care unit admission or surgery.10Cotton P.B. Outcomes of endoscopy procedures struggling towards definitions.Gastrointest Endosc. 1994; 40: 514-518Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar Patients who developed complications were identified by examining discharge summaries, clinic notes, emergency department notes, phone conversation notes, referring physician correspondence, and laboratory and radiologic data occurring after the procedure in the computerized hospital medical record systems. For the complications, further data were collected including symptoms, temperature, comorbidities, medications, hospitalization, length of hospital stay, laboratory and radiologic data, diagnostic work-up, and treatment. Quantitative data were summarized as the mean (±1 SEM). Comparative univariate analyses were performed by using the Student t test, χ2 test, or Fisher exact test as appropriate. A 2-tailed P value <.05 was considered statistically significant. A total of 603 patients underwent EUS FNA of 651 pancreatic cystic lesions. The mean age of the patients was 63 ± .6 years with 62% women. Table 1 shows the baseline characteristics of the patient population. Data on cyst location were available for 622 cystic lesions. Cysts were located most commonly in the pancreatic head (310 of 622). Forty-one of these 622 lesions were classified as occupying multiple regions of the pancreas. Mean cyst size was 25.6 ± 0.7 mm. The median number of passes was 1 (range, 1–5 passes). Prophylactic antibiotics were administered in 90% (543 of 603) of cases.Table 1Baseline Patient Characteristics and Procedures PerformedBaseline characteristics Mean age (y)63 ± 0.6 Women62%Cyst location Head50% (310/622) Body23% (142/622) Tail21% (129/622) Multiple locations6% (41/622)Cyst characteristic Mean cyst size (mm)25.6 ± 0.7 Unilocular50% Multilocular37% Cystic mass13%Procedure characteristic Median number of passes1 (range, 1–5) Median needle gauge22 (range, 19–25) Prophylactic antibiotic90% (543/603) Inpatient during EUS12% (72/603) Same-day ERCP10% (61/603) Open table in a new tab Final pathology diagnosis by surgical resection was available in 197 cases. Table 2 shows the distribution of diagnoses with 66% benign lesions. The diagnoses included mucinous cystic neoplasm, intraductal papillary mucinous tumor, pancreatic adenocarcinoma, chronic pancreatitis, pseudocyst, and serous cystadenoma. Borderline lesions were included in the category of malignant lesions arising from intraductal papillary mucinous tumors and mucinous cystic neoplasms. Cytology provided a specific diagnosis in only 16% of cases, with similar diagnostic rates for malignant (14 of 66, 21%) and benign cysts (17 of 131, 13%; P > .05).Table 2Surgical Pathology DiagnosesPathology diagnosisnBenign Mucinous cystadenoma (benign, low-grade dysplasia, moderate dysplasia)39 IPMT (benign, low-grade dysplasia, moderate dysplasia)30 Pseudocyst17 Chronic pancreatitis13 Serous cystadenoma12 Neuroendocrine8 Others12Malignant Adenocarcinoma29 IPMT adenocarcinoma23 Mucinous cystadenocarcinoma7 Neuroendocrine carcinoma2 Metastatic carcinoma2 Others3IPMT, intraductal papillary mucinous tumor. Open table in a new tab IPMT, intraductal papillary mucinous tumor. The overall complication rate was 2.2% (13 of 603 patients), with 1 immediate and 12 early complications. Nine complications (69%) were classified as mild; 3 complications were classified as moderate and 1 was classified as severe. There were no deaths and no patients required surgery. The 13 patients had a mean age of 64 ± 4.8 years and 85% were women. Twelve patients were hospitalized with a mean length of stay of 3.8 ± 1.1 days. The mean cyst size was 30.9 ± 4.7 mm with 62% unilocular, 38% multilocular, and no cystic masses. All had received prophylactic antibiotics and underwent EUS as outpatients; 23% also completed ERCP on the same day. The distribution of complications was as follows: 46% (6 patients) pancreatitis, 30% (4 patients) nonspecific abdominal pain, 8% (1 patient) infection, 8% (1 patient) retroperitoneal bleed, and 8% (1 patient) bradycardia. All patients with pancreatitis presented with abdominal pain and increased amylase and lipase levels. Four patients were women and only 1 patient had undergone same-day ERCP. Pancreatography during this ERCP showed a probable pseudocyst communicating with the main pancreatic duct. Four pancreatic cysts were located in the head, 1 in the body of the pancreas, and 1 in the tail of the pancreas. Three cases of pancreatitis were mild according to the severity index from the consensus conference11Cotton P.B. Lehman G. Vennes J. et al.Endoscopic sphincterotomy complications and their management an attempt at consensus.Gastrointest Endosc. 1991; 37: 383-393Abstract Full Text PDF PubMed Scopus (2446) Google Scholar and one was classified as severe requiring total parenteral nutrition but not percutaneous drainage or surgical management. This patient had a small pancreatic cyst in the tail and had not undergone same-day ERCP or had a history of pancreatitis, although the patient did have a history of heavy alcohol intake. The computed tomography scan showed possible necrosis. All 4 patients with nonspecific abdominal pain were women and 3 of the patients had no history of abdominal pain preceding the EUS FNA. One patient had a history of intermittent epigastric discomfort before the procedure and it is unclear whether the pain postprocedure was a result of the EUS FNA. Two patients had undergone ERCP with EUS FNA. In 1 patient, the pancreatic duct could not be cannulated at ERCP despite multiple attempts whereas in the other patient the pancreatogram showed an irregular pancreatic duct in the tail consistent with chronic pancreatitis, with evidence of a pseudocyst communicating with the duct in this region. Both patients eventually underwent surgical resection and pathology showed mucinous cystic neoplasm in the former patient and chronic pancreatitis with a pseudocyst in the latter patient. The surgical specimen from a third patient was consistent with intraductal papillary mucinous tumor. Three patients were admitted for 1 day of observation and 1 patient was treated with oral antibiotics as an outpatient. All patients had normal laboratory examination. One patient with probable infection presented with fever, abdominal pain, and an increased white blood cell count. The aspirated cyst was a 5-cm multiloculated lesion. The patient's symptoms resolved overnight with administration of intravenous antibiotics and an abdominal computed tomography scan showed the cyst in the tail of the pancreas without evidence of leakage, perforation, or peripancreatic inflammation. Blood and urine cultures revealed no growth. The patient with retroperitoneal bleeding presented with abdominal pain and responded to conservative management with blood transfusion of 1 U. She was taking aspirin and prednisone at the time of EUS FNA. One patient experienced significant bradycardia with a heart rate in the 20s. This spontaneously resolved and she was admitted overnight for observation. Univariate analysis was performed to identify predictors of complications (Table 3). In patients with complications there was a trend toward larger cysts and cysts located in the tail, but no single predictor was significant. Pancreatitis rates were similar for the 61 patients undergoing same-day ERCP and EUS FNA (1.6%) compared with the 542 patients completing only EUS FNA (.9%, P > .05). Nonspecific abdominal pain occurred more frequently after both ERCP and EUS FNA (3.3%) than after EUS FNA alone (0.4%) (P = .053). Overall complication rates were similar for patients who underwent both ERCP with EUS FNA (4.9%) and EUS FNA alone (2.0%) (P > .05).Table 3Predictors of EUS FNA-Associated ComplicationsCharacteristicsComplications (n = 13)No complications (n = 590)Mean age (y)64 ± 4.863 ± 0.6Women 85%61%Cyst characteristic Mean cyst size (mm)30.9 ± 4.725.4 ± 0.7 Unilocular 62%49% Multilocular 38%37% Cystic mass 0%14% Head 43%50% Body 21%23% Tail 36%20% Multiple locations 0% 7%Procedure characteristic Median number of passes 1 (range, 1–5) 1 (range, 1–5) Median needle gauge22 (only 22)22 (range, 19–25) Prophylactic antibiotic100% 90% Inpatient during EUS 0% 12% Same-day ERCP 23% 10% Open table in a new tab No complications were observed in the 60 patients who had not received prophylactic antibiotics. These patients were compared with those who did receive antibiotics (Table 4). Mean cyst size was smaller for patients who were not administered prophylactic antibiotics at 19.4 ± 1.5 mm compared with those who were given antibiotics at 26.4 ± .8 mm, P = .005. In addition, the patients who were not administered antibiotics were younger and usually underwent EUS FNA as outpatients without concurrent ERCP.Table 4Relationship of Use of Antibiotics, Cyst Characteristics, and Procedure on Risk of ComplicationsCharacteristicsNo antibiotics (n = 60)Antibiotics (n = 543)P valueComplications0%2.4%NSMean age (y) 56 ± 2.0 64 ± 0.6.0001Women72%60%NSMean cyst size (mm)19.4 ± 1.526.4 ± 0.8.005Unilocular50%50%NSMultilocular37%36%NSCystic mass13%14%NSInpatient during EUS3%13%.033Same-day ERCP2%11%.021NS, not specified. Open table in a new tab NS, not specified. In this large series of EUS-guided pancreatic cyst aspiration, we show that EUS FNA of pancreatic cysts is safer than previously thought, with a complication rate of 2.2%. This is comparable with the overall complication rate for colonoscopy with polypectomy12American Society for Gastrointestinal EndoscopyComplications of colonoscopy.Gastrointest Endosc. 2003; 57: 441-444Abstract Full Text PDF PubMed Scopus (155) Google Scholar and ultrasound or computed tomography-guided biopsy examination of pancreatic lesions.13Di Stasi M. Lencioni R. Solmi L. et al.Ultrasound-guided fine needle biopsy of pancreatic masses results of a multicenter study.Am J Gastroenterol. 1998; 93: 1329-1333Crossref PubMed Scopus (119) Google Scholar, 14Brandt K.R. Carboneau J.W. Stephens D.H. et al.CT- and US-guided biopsy of the pancreas.Radiology. 1993; 187: 99-104PubMed Google Scholar All complications occurred within 30 days of the procedure, which is consistent with a recent prospective study evaluating EUS FNA of solid pancreatic masses in which no complications were found beyond 30 days.5Eloubeidi M.A. Chen V.K. Eltoum I.A. et al.Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer diagnostic accuracy and acute 30-day complications.Am J Gastroenterol. 2003; 98: 2663-2668PubMed Google Scholar The rate of severe complications was .2%, with no patient requiring surgical management. Nearly half of the complications were pancreatitis; other rare complications included abdominal pain, infection, and retroperitoneal bleeding. One serious limitation in the literature of endoscopic complications is the lack of consensus in the definition, classification, and grading of complications. Classification of complications into immediate, early, and delayed events is borrowed from the surgical literature.10Cotton P.B. Outcomes of endoscopy procedures struggling towards definitions.Gastrointest Endosc. 1994; 40: 514-518Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar In an attempt to promote consensus in the gastrointestinal literature, Cotton11Cotton P.B. Lehman G. Vennes J. et al.Endoscopic sphincterotomy complications and their management an attempt at consensus.Gastrointest Endosc. 1991; 37: 383-393Abstract Full Text PDF PubMed Scopus (2446) Google Scholar proposed using the length of hospitalization to grade the severity of complications, which was adapted from the criteria used to define complications after ERCP. This system has never been validated. Fleischer15Fleischer D.E. Better definition of endoscopic complications and other negative outcomes.Gastrointest Endosc. 1994; 40: 511-514Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar proposed adapting the Clavien et al.16Clavien P.A. Sanabria J.R. Strasberg S.M. Proposed classification of complications of surgery with examples of utility in cholecystectomy.Surgery. 1992; 111: 518-526PubMed Google Scholar grading system from surgery that stratifies complications based on the presence of residual disability and need for invasive procedures. Subsequently, a scoring system was developed to define, classify, and grade negative outcomes but this has not been validated prospectively.17Fleischer D.E. Van de Mierop F. Eisen G.M. et al.A new system for defining endoscopic complications emphasizing the measure of importance.Gastrointest Endosc. 1997; 45: 128-133Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Therefore, it is difficult to compare studies examining negative outcomes of gastrointestinal procedures. Initial studies of EUS FNA included a variety of solid and cystic lesions, with consistently higher complication rates for cystic lesions. Fourteen percent of cyst aspirations developed complications in 1 prospective study, but there were only 22 cystic lesions in this study, of which 18 were in the pancreas.4Wiersema M.J. Vilmann P. Giovannini M. et al.Endosonography-guided fine-needle aspiration biopsy diagnostic accuracy and complication assessment.Gastroenterology. 1997; 112: 1087-1095Abstract Full Text PDF PubMed Scopus (1104) Google Scholar All of the complications occurred during the first 3 years of the study, from 1991 to 1993. Two patients required surgery and the third patient responded to conservative management for fever. It is unclear why the complication rate was dramatically higher in this study. One could hypothesize that image quality was poorer with the older processors leading to decreased needle visibility and increased complication rates, or perhaps these FNAs were performed early in the experience of the endosonographers. A more recent retrospective study examining aspirations of 114 pancreatic cysts noted a lower complication rate of 3.5% for cystic lesions. There were 3 cases of pancreatitis that responded to conservative management within 48 hours and 1 episode of self-limited intracystic hemorrhage without clinical evidence of bleeding.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar In our study the rate of pancreatitis was 1.0%, which is similar to that generally reported in the literature of .29% to 2.3% after EUS FNA of solid pancreatic masses.6Harewood G.C. Wiersema M.J. Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses.Am J Gastroenterol. 2002; 97: 1386-1391Crossref PubMed Google Scholar, 18Gress F. Michael H. Gelrud D. et al.EUS-guided fine-needle aspiration of the pancreas evaluation of pancreatitis as a complication.Gastrointest Endosc. 2002; 56: 864-867Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar, 19Gress F.G. Hawes R.H. Savides T.J. et al.Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography.Gastrointest Endosc. 1997; 45: 243-250Abstract Full Text Full Text PDF PubMed Scopus (386) Google Scholar, 20Binmoeller K.F. Brand B. Thul R. et al.EUS-guided, fine-needle aspiration biopsy using a new mechanical scanning puncture echoendoscope.Gastrointest Endosc. 1998; 47: 335-340Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 21Eloubeidi M.A. Gress F.G. Savides T.J. et al.Acute pancreatitis after EUS-guided FNA of solid pancreatic masses a pooled analysis from EUS centers in the United States.Gastrointest Endosc. 2004; 60: 385-389Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar A recent history of pancreatitis has been thought to increase the risk for pancreatitis after EUS FNA.18Gress F. Michael H. Gelrud D. et al.EUS-guided fine-needle aspiration of the pancreas evaluation of pancreatitis as a complication.Gastrointest Endosc. 2002; 56: 864-867Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar There was no history of pancreatitis in the 6 patients who developed pancreatitis in this study, although 2 patients had a history of heavy alcohol use. In addition, FNA of cysts in the head or uncinate process has been thought to promote pancreatitis owing to the longer distance the needle passes through normal pancreas tissue during aspiration.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar Consistent with this theory, the majority of cysts (67%) in our cases of pancreatitis were located in the head, with only 1 cyst in the body and 1 in the tail. Hemorrhagic and infectious complications were feared during the early days of EUS-guided aspirations of cystic lesions. Similar to other studies, some of which used Doppler guidance, the rate of bleeding complications was low in our study at .2% and was self-limited.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar, 20Binmoeller K.F. Brand B. Thul R. et al.EUS-guided, fine-needle aspiration biopsy using a new mechanical scanning puncture echoendoscope.Gastrointest Endosc. 1998; 47: 335-340Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 22Affi A. Vazquez-Sequeiros E. Norton I.D. et al.Acute extraluminal hemorrhage associated with EUS-guided fine needle aspiration frequency and clinical significance.Gastrointest Endosc. 2001; 53: 221-225Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 23Varadarajulu S. Eloubeidi M.A. Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas.Gastrointest Endosc. 2004; 60: 631-635Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar There was one possible infection with fever and an increased white blood cell count that responded rapidly to antibiotic therapy. This is consistent with a recent retrospective study that found no infectious complications after 114 pancreatic cyst aspirations for which prophylactic antibiotics had been administered in two thirds of the procedures.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar Other studies have suggested a higher rate of infectious complications after pancreatic cyst aspirations despite the use of prophylactic antibiotics.4Wiersema M.J. Vilmann P. Giovannini M. et al.Endosonography-guided fine-needle aspiration biopsy diagnostic accuracy and complication assessment.Gastroenterology. 1997; 112: 1087-1095Abstract Full Text PDF PubMed Scopus (1104) Google Scholar, 24Williams D.B. Sahai A.V. Aabakken L. et al.Endoscopic ultrasound guided fine needle aspiration biopsy a large single center experience.Gut. 1999; 44: 720-726Crossref PubMed Scopus (591) Google Scholar We believe that complete evacuation of the cyst is a key factor in limiting infectious complications. The overwhelming majority of patients received prophylactic antibiotics in this study. In the 60 patients who were not administered antibiotics, there were no complications and the mean cyst size was smaller. This may reflect the practice bias of endosonographers who give antibiotics to patients with larger multiloculated cysts. The patients not given antibiotics may represent a healthier cohort because more were younger outpatients at the time of EUS FNA. Therefore, it is unclear at this time whether prophylactic antibiotics must be administered for every endoscopic cyst aspiration. In our practice, patients with completely evacuated large or complex cysts typically are given a fluoroquinolone for 3 days after EUS FNA whereas intravenous antibiotics are administered during the procedure if the cyst aspiration was incomplete. No consensus exists among investigators regarding antibiotic use in aspiration of small cysts. There may be a group of relatively healthy patients with smaller cysts that when completely aspirated do not require antibiotics, but no specific recommendations can be made based on our retrospective data. There was a trend toward an increased complication rate after undergoing both ERCP and EUS FNA on the same day compared with EUS-FNA alone. This most likely reflects the higher complication rate of ERCP. We noted significantly higher rates of nonspecific abdominal pain after both procedures as well as a trend toward more pancreatitis, which did not reach statistical significance, likely because of the small number of patients who underwent both procedures in our study. The retrospective nature of this study was a limitation, however, the large number of pancreatic cyst aspirations reflects current practice and a prospective study of similar size would be difficult to achieve. Our results also are similar to those of a recent smaller study examining complications of EUS FNA in cyst aspirations.8O'Toole D. Palazzo L. Arotcarena R. et al.Assessment of complications of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2001; 53: 470-474Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar Although the goal of aspiration was to collapse the cyst completely, these data were not documented fully in the endoscopy notes and, therefore, we could not analyze this variable in our study. In addition, the small number of complications in our study limits our ability to identify significant predictors of these complications. Finally, our low complication rate may partly result from a volume-related level of expertise seen at academic centers. Our results are consistent with the more recent literature from other academic institutions regarding such complications. Therefore, the current literature may be more reflective of the practice of endosonography in tertiary care referral centers rather than in the general community. In this series of EUS-guided pancreatic cyst aspirations, the overall complication rate was low at 2.2% and no obvious predictors of the complications were identified. Smaller cysts were aspirated safely without prophylactic antibiotics, and further prospective study is necessary to determine the appropriate use of antibiotics in EUS FNA of pancreatic cysts. The combination of EUS FNA and ERCP may increase the complication rate compared with EUS FNA alone, but our study did not show a significant additive effect. This study confirms that EUS FNA of pancreatic cysts is safe, with an adverse-event profile similar to EUS FNA of solid lesions.