Abstract
Background and Objective:
The optimal timing between endoscopic retrograde cholangiopancreatography (ERCP) and EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) remains undefined. This study compared The optimal timing between endoscopic retrograde cholangiopancreatography (ERCP) and EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) remains undefined. This study compared the safety and efficacy of same-day versus separate-day procedures.the safety and efficacy of same-day versus separate-day procedures.
Methods:
We conducted a retrospective analysis of 362 patients with pancreatic mass and biliary obstruction who underwent EUS-FNA/B and ERCP during one hospitalization period at Changhai Hospital between January 2017 and February 2024. Outcomes included adverse events, technical success of biliary stenting, and diagnostic yield of EUS-FNA/B. Logistic regression identified risk factors for adverse events.
Results:
Patients were stratified into same-day (group A, n = 60) and separate-day (group B, n = 302) groups. No perforations occurred in either group. Rates of pancreatitis (10.0% vs. 9.3%), infection (10.0% vs. 8.3%), and bleeding (1.7% vs. 3.7%) were comparable (all P > 0.05). Technical success of biliary stenting (96.7% vs. 96.7%) and diagnostic yield of EUS-FNA/B (80.0% vs. 84.8%) showed no intergroup differences. Notably, same-day procedures significantly shortened median hospital stay (6 [4–8.75] days vs. 7 [6–10] days, P = 0.002). Multivariable analysis identified advancing age (odds ratio [OR]: 0.957; 95% confidence interval [CI], 0.924–0.991; P = 0.014) and larger mass short-axis diameter (OR: 0.918; 95% CI, 0.868–0.971; P = 0.003) as independent protective factors against pancreatitis, while overweight status (body mass index > 23.9 kg/m2) increased pancreatitis risk (OR: 3.491; 95% CI, 1.574–7.744; P = 0.002). Precut sphincterotomy was independently associated with bleeding risk (OR: 1.607; 95% CI, 1.230–20.242; P = 0.024). Crucially, the same-day procedure was not linked to increased adverse events.
Conclusion:
Same-day ERCP and EUS-FNA/B is safe and feasible, does not increase adverse events, and reduces hospital stay.
Keywords: EUS, guided fine, needle aspiration/biopsy, endoscopic retrograde cholangiopancreatography, pancreatic disease, biliary obstruction
INTRODUCTION
Pancreatic masses are radiologically characterized by focal or diffuse parenchymal enlargement, frequently accompanied by concurrent dilation of the biliary and/or pancreatic ducts. Pancreatic masses mostly include ductal adenocarcinoma, but also lymphoma, neuroendocrine tumors, metastases, solid pseudopapillary tumor, and benign conditions such as autoimmune pancreatitis and focal pancreatitis.[1] Approximately 85% of pancreatic masses ultimately prove to be malignant neoplasms,[2]with over 20% of pancreatic malignancies presenting as surgically unresectable due to locally advanced disease or distant metastases.[3] The histopathological confirmation is imperative as mass biology fundamentally dictates therapeutic algorithms and long-term clinical outcomes. Furthermore, malignant biliary obstruction secondary to mass effect precipitates a cascade of hepatobiliary complications, including cholangitis, cholemia-induced pruritus, progressive hepatocellular dysfunction, and coagulation disorders.[4] Therefore, relieving the obstruction of the biliary tract is also of great significance.
EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has emerged as the first-line diagnostic modality for histological acquisition in pancreatic lesions.[1] This minimally invasive technique provides triple clinical benefits: (1) obtaining adequate core specimens for molecular profiling, (2) generating high-resolution cross-sectional imaging for tumor node metastasis staging (particularly vascular involvement assessment), and (3) facilitating subsequent therapeutic endoscopic retrograde cholangiopancreatography (ERCP). ERCP with placement of a biliary stent has been established as the first-line therapeutic intervention for both benign and malignant common bile duct strictures.[5] The success rate of biliary stent placement was as high as 90%, and the incidence of postprocedural adverse events and mortality is significantly lower than that of hepaticojejunostomy.[4] For pancreatic mass patients complicated with biliary obstruction, the recommended diagnostic-therapeutic plan is EUS-FNA/B for histopathological confirmation and ERCP for biliary decompression.
Both EUS-FNA/B and ERCP have the risk of developing adverse events, including pancreatitis, bleeding, perforation, and infection. Notably, post-FNA/B parenchymal edema increases the difficulty of ERCP selective cannulation, while poststent inflammatory changes, biliary gas accumulation, and acoustic shadowing decrease EUS visualization and the selection of the FNA/B puncture path.[6] Both would interact with each other and may increase the occurrence of adverse events. The 2025 National Comprehensive Cancer Network guidelines recommend same-anesthesia combined EUS-ERCP for pancreatic cancer with obstructive jaundice, but current evidence remains insufficient.[7] Fisher et al.[6] found that the patients with early EUS-FNA performed within 24 hours post–biliary stenting were more likely to have indeterminate results from the EUS-FNA than the patients who underwent EUS-FNA after 24 hours (P = 0.008). Current clinical protocols typically maintain a ≥24-hour interval between sequential endoscopic procedures, which may contribute to the regression of periampullary edema and reduce the risk of postprocedural adverse events and the difficulty of the operation, since the postprocedural adverse events mostly occur within 24 hours after the procedure.[8] However, Benjaminov et al.[9] reported that patients with biliary obstruction were at an increased risk of developing cholangitis and liver function impairment during the waiting period for therapeutic ERCP, which contradicts clinical practice. Therefore, we conducted a study that compared postprocedural adverse event rates and success rates of same-day versus separate-day operations in patients requiring both procedures, aiming to establish evidence-based recommendations for same-day endoscopic procedures.
MATERIALS AND METHODS
Patient selection
We conducted a retrospective cohort analysis of patients with pancreatic mass and concomitant biliary obstruction who underwent combined EUS-FNA/B with ERCP-guided biliary stenting during a single hospitalization at the Digestive Disease Center of the First Affiliated Hospital of Naval Medical University (Shanghai, China) between January 2017 and February 2024. Patients were excluded from the analysis for the following reasons: identification of extra-pancreatic mass lesions on EUS, diagnosis of chronic pancreatitis, or missing important clinical data.
This study strictly adhered to the principles of the Declaration of Helsinki and the International Ethical Guidelines for Biomedical Research Involving Human Subjects jointly developed by the World Health Organization and the Council for International Organizations of Medical Sciences. This study was approved by the ethics committee of Changhai Hospital. All patients were exempted from informed consent.
Procedures of EUS-FNA/B and ERCP
Biliary drainage is indicated for patients demonstrating imaging evidence of intrahepatic and extrahepatic bile duct dilation, serum total bilirubin >3 mg/dL, or symptoms suggestive of cholangitis for palliative biliary drainage. Preoperative biliary drainage should be reserved for patients with cholangitis, severe symptomatic jaundice (e.g., intense pruritus), or delayed surgery, and for jaundiced patients scheduled to undergo neoadjuvant chemotherapy. Severe symptomatic jaundice is a total serum bilirubin ≥250 µmol/L. EUS-FNA/B or ERCP procedures were performed following administration of adjuvant sedatives, including intravenous diazepam (5 mg), pethidine (50 mg), and scopolamine butylbromide (20 mg); propofol 2 mg/kg or sufentanil 2 mL via slow intravenous injection; and under monitored anesthesia care provided by an anesthesiologist. If 2 procedures are scheduled on the same day, as we do not perform consecutive surgeries, the anesthesia for the second procedure will be administered only after the patient has fully recovered from the previous anesthesia. Additionally, the anesthetic dosage for the second procedure will be appropriately reduced. Before EUS initiation, pre-existing radiological data were systematically reviewed to localize primary lesions based on cross-sectional imaging findings from computed tomography scans or magnetic resonance imaging. The EUS-FNA/B procedure was performed using a linear-array echo endoscope (GF-UC240 P-AL5; Olympus, Tokyo, Japan), EUS biopsy needles (ECHO-3-22, Cook Japan Inc, Tokyo, Japan), and a 22- or 25-gauge EUS–fine needle aspiration needle (EZ Shot, Olympus; EchoTip, Cook Japan Inc, Tokyo, Japan; or Expect, Boston Scientific Japan K.K., Tokyo, Japan). The morphological features and cross-sectional dimensions of masses were documented, with particular attention to vascular invasion patterns and adjacent organ infiltration. Tissue acquisition was achieved through puncture using 22- or 25-gauge EUS-specific needles, followed by immediate postextraction observation for needle tract bleeding. ERCP procedure was performed using the electronic gastroduodenoscope (JF-260V, TJF-260V; Olympus), and the duodenal papilla morphology was systematically assessed before attempted biliary cannulation. Following successful cannulation, iodinated contrast medium was administered at a controlled injection rate under fluoroscopic guidance to detect the presence of biliary strictures and quantify stricture length. Guidewire-assisted biliary stent placement was performed using the through-the-scope technique. After the operation, the patient was required to fast and abstain from drinking for 24 hours. Routine treatments such as acid suppression, fluid replacement, and administration of antibiotics were given. All endoscopic procedures were performed by an expert who had performed more than 500 EUS-FNA/FNB procedures and less than 1000 ERCP.
Outcome measurements
Primary outcome
The primary outcome was the rate of postprocedural adverse events, including pancreatitis, infection, bleeding, and perforation. The definition of each adverse events are based on those provided in 2019 ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. ESGE suggests to define post-ERCP pancreatitis as new or worsened abdominal pain combined with >3 times (>405 U/L) the normal value of amylase or lipase at more than 24 hours after ERCP and requirement of admission or prolongation of a planned admission. Infections include cholangitis, cholecystitis, and endoscopy-related infections. Cholangitis is defined as new onset temperature >38 °C for more than 24 hours combined with cholestasis. Cholecystitis is defined as right upper quadrant signs of inflammation systemic signs of inflammation such as white blood cell count >10 × 109/L and proportion of neutrophils >80% or procalcitonin >0.05 ng/mL, and imaging findings characteristic of acute cholecystitis, without any suggestive clinical or imaging findings before procedure. Bleeding was defined as the occurrence of intraoperative active bleeding requiring hemostasis, postoperative hematemesis and/or melena, or a postoperative hemoglobin drop of >2 g/dL. Perforation is defined as evidence of gas or luminal contents outside of the gastrointestinal tract as determined by imaging.
Secondary outcomes
The secondary outcomes were procedural success rate, the diagnostic yield of EUS-FNA/B, and the length of hospital stay. Additionally, a multivariate logistic regression analysis was performed to identify risk factors for endoscopy-associated adverse events (pancreatitis, infection, bleeding, and perforation). The ERCP technical success is defined as successful biliary stent placement during ERCP procedure. The diagnostic yield of EUS-FNA/B is defined as a clear diagnosis of pancreatic malignancy or autoimmune pancreatitis. Pancreatic malignancy is defined by postoperative histopathology showing malignant cells or cells suspicious for malignancy. Autoimmune pancreatitis is defined as pancreatic tissue containing sparse acinar cells with fibrosis, accompanied by ≥50 IgG4-positive plasma cells per 20 high-power fields and an IgG4/IgG ratio >50% on immunohistochemical analysis.
Statistical analysis
Statistical analysis was performed using SPSS 26.0 software (IBM Corp., Armonk, NY, USA). Normally distributed continuous variables are expressed as mean ± standard deviation, nonnormally distributed continuous variables as median with interquartile range, and categorical variables as percentages. Group comparisons were conducted using Student’s t test or nonparametric tests for continuous variables and chi-square test for categorical variables. Logistic regression analysis was employed to identify risk factors for adverse events, including pancreatitis, infection, bleeding, and perforation. Variables with P < 0.1 in univariate analysis were included in the multivariate logistic regression model. Risk factors were quantified using odds ratios (ORs) with 95% confidence intervals (CIs). A 2-tailed P < 0.05 was considered statistically significant for all analyses.
RESULTS
Patient demographics and clinical characteristics
A total of 393 clinical records of patients undergoing EUS-FNA/B and ERCP during the same hospitalization period at Changhai Hospital from January 2017 to February 2024 were retrospectively reviewed. Twelve chronic pancreatitis, 12 extra-pancreatic mass, 3 undergoing percutaneous transhepatic cholangio drainage without prior ERCP biliary stenting attempts, and 4 with incomplete clinical documentation were excluded. The flowchart of participant selection is shown in Figure 1.
Figure 1.
Flowchart of participant selection from the Changhai Hospital database. ERCP, endoscopic retrograde cholangiopancreatography; EUS-FNA/B, EUS-guided fine-needle aspiration/biopsy; PTCD, percutaneous transhepatic cholangio drainage.
As shown in Table 1, the study enrolled 362 patients, including 60 cases in the same-day group (group A, 35 males, median age: 66 years) and 302 cases in the separate-day group (group B, 197 males, median age: 64 years). No significant differences were observed in age, sex, or clinical manifestations between groups. However, group A exhibited significantly higher total bilirubin (P = 0.037) and direct bilirubin levels (P = 0.039), a higher prevalence of hypertension (P = 0.029), and smaller mass short-axis diameters (P = 0.041) compared with group B.
Table 1.
Patient demographics and clinical characteristics.
| Group A (n = 60) | Group B (n = 302) | P value | |
|---|---|---|---|
| Age (yr) | 66 (55–72) | 64 (56–70) | 0.223 |
| Male, n (%) | 35 (58.3%) | 197 (65.2%) | 0.309 |
| BMI (kg/m2), mean ± SD | 21.63 ± 2.48 | 21.76 ± 2.95 | 0.741 |
| Total bilirubin (μmol/L), median (IQR) | 171.3 (93.55–295.78) | 133.1 (62.02–242.43)* | 0.037 |
| Direct bilirubin (μmol/L), median (IQR) | 114.4 (67.05–223.98) | 97.65 (39.58–181.40)* | 0.039 |
| ALP (U/L), median (IQR) | 412.5 (255.5–861.5) | 406.5 (255.5–622.5) | 0.356 |
| γ-GGT (U/L), median (IQR) | 591 (322.50–1036.50) | 533.5 (251.75–883.75) | 0.167 |
| Pancreatic mass long axis (mm), median (IQR) | 32 (26–37)† | 35 (28–39)† | 0.057 |
| Pancreatic mass short axis (mm), median (IQR) | 25.63 (20.7–30)† | 28.50 (23–32)† | 0.041 |
| Previous ERCP, n (%) | 3 (5.0%) | 19 (6.3%) | 0.695 |
| Previous pancreatitis, n (%) | 6 (10.0%) | 27 (8.9%) | 0.795 |
| Previous PTCD, n (%) | 4 (6.7%) | 21 (7.0%) | 0.936 |
| Diabetes, n (%) | 16 (26.7%) | 73 (24.2%) | 0.682 |
| Hypertension, n (%) | 27 (45.0%) | 92 (30.5%) | 0.029 |
| Obstructive jaundice, n (%) | 53 (83.3%) | 239 (79.1%) | 0.100 |
| Abdominal pain, n (%) | 42 (70.0%) | 180 (59.6%) | 0.131 |
| Proximal biliary obstruction, n (%) | 1 (1.7%) | 6 (2.0%) | 0.867 |
| Location of the mass | 0.420 | ||
| Pancreatic head + neck, n (%) | 56 (93.3%) | 269 (89.1%) | |
| Pancreatic body + tail, n (%) | 1 (1.7%) | 15 (5.0%) | |
| Diffuse enlargement, n (%) The time interval between 2 operations (d) |
3 (5.0%) 0 |
18 (6.0%) 2 (1–3) |
One case in Group B underwent median imputation for missing TB and DB values.
Pancreatic mass long-axis and short-axis diameter were unavailable in 39 cases from group B and 3 cases from group A on EUS reports, with median values substituted for missing data.
ALP, alkaline phosphatase; BMI, body mass index; DB, direct bilirubin; ERCP, endoscopic retrograde cholangiopancreatography; γ-GGT, gamma-glutamyl transferase; IQR, interquartile range; PTCD, percutaneous transhepatic cholangiodrainage; SD, standard deviation; TB, total bilirubin.
Incidence of postprocedural adverse events
The incidence of postprocedural adverse events is detailed in Table 2. No perforation occurred in any patient. In group A, 6 cases of pancreatitis (10.0%), 6 cases of infection (10.0%), and 1 case of bleeding (1.7%) were observed, while 28 cases of pancreatitis (9.3%), 25 cases of infection (8.3%), and 11 cases of bleeding (3.7%) were observed in group B. No statistically significant differences were observed between the 2 groups in the incidence of pancreatitis, infection, or bleeding (all P > 0.05).
Table 2.
The incidence of postprocedural adverse events.
| Group A (n = 60) | Group B (n = 302) | P value | |
|---|---|---|---|
| Pancreatitis | 6 (10.0%) | 28 (9.3%) | 0.860 |
| Infection | 6 (10.0%) | 25 (8.3%) | 0.663 |
| Bleeding | 1 (1.7%) | 11 (3.7%) | 0.433 |
| Perforation | 0 | 0 |
Success rate of endoscopic procedures
As shown in Table 3, no significant differences were observed between groups in the technical success rate of ERCP with biliary stent placement (96.7% vs. 96.7%, P = 0.993) and diagnostic yield (80.0% vs. 84.8%, P = 0.358). Pancreatic malignancy was the most prevalent diagnosis in both groups, 71.7% of cases in group A and 72.5% in group B.
Table 3.
Endoscopic characteristics.
| Group A (n = 60) | Group B (n = 302) | P value | |
|---|---|---|---|
| Procedure of ERCP | |||
| Endoscopic sphincterotomy, n (%) | 44 (73.3%) | 186 (61.6%) | 0.084 |
| Precut sphincterotomy, n (%) | 7 (11.7%) | 20 (6.6%) | 0.199 |
| IDUS, n (%) | 3 (5.0%) | 8 (2.6%) | 0.365 |
| Brush biopsy, n (%) | 9 (15.0%) | 70 (23.2%) | 0.161 |
| Biliary stents | |||
| Metal stents, n (%) | 43 (71.7%) | 205 (67.9%) | 0.564 |
| Plastic stents, n (%) | 15 (25.0%) | 87 (28.8%) | 0.549 |
| Pancreatic drainage, n (%) | 14 (23.3%) | 72 (23.8%)* | 0.933 |
| Endoscopic nasobiliary drainage, n (%) | 3 (5.0%) | 7 (2.3%) | 0.467 |
| Placement rate of biliary stents, n (%) | 58 (96.7%) | 292 (96.7%) | 0.993 |
| Procedure of EUS-FNA/B | |||
| No. of FNA/B passes, median (IQR) | 3 (2.25–4) | 3 (2–4) | 0.861 |
| Diagnosis yield, n (%) | 48 (80.0%) | 256 (84.8%) | 0.358 |
| Diagnosis | 0.502 | ||
| Pancreatic cancer, n (%) | 43 (71.7%) | 219 (72.5%) | |
| Autoimmune pancreatitis, n (%) | 5 (8.3%) | 37 (12.3%) | |
| Indeterminate/atypical, n (%) | 12 (20.0%) | 46 (15.2%) |
One nasopancreatic duct drainage was performed in 1 case from group B.
ERCP, endoscopic retrograde cholangiopancreatography; EUS-FNA/B, EUS-guided fine-needle aspiration/biopsy; IDUS, intraductal ultrasonography.
Length of hospital stay
Group A demonstrated significantly shorter median hospital stay (6 [4–8.75] vs. 7 [6–10] days, P = 0.002). The median surgical interval of group B was 2 (1–3) days [Figure 2].
Figure 2.
Comparison of the length of hospital stay between the 2 groups.
Logistic regression analysis of risk factors
Univariate analysis of potential predictors for postprocedural pancreatitis revealed that advanced age (P = 0.009) and larger mass short-axis diameter (P = 0.011) served as protective factors, while overweight status (P < 0.001) constituted a significant risk factor [Table 4]. Subsequent multivariate analysis incorporating total bilirubin, hypertension, mass short-axis diameter, age, and overweight status confirmed age (OR: 0.957; 95% CI, 0.924–0.991; P = 0.014) and larger mass short-axis diameter (OR: 0.918; 95% CI, 0.868–0.971; P = 0.003) as independent protective factors, with overweight remaining a robust risk determinant (OR: 3.491; 95% CI, 1.574–7.744; P = 0.002) [Table 5]. Both univariate and multivariate analyses identified precut sphincterotomy as an independent risk factor for bleeding (OR: 4.989; 95% CI, 1.230–20.242; P = 0.024). No independent predictors were identified for infection. Notably, same-day procedures did not demonstrate a significant association with postprocedural adverse events.
Table 4.
Univariate logistic regression analysis of postprocedural adverse events.
| Complication | Factors | B value | OR | 95% CI | P value |
|---|---|---|---|---|---|
| Pancreatitis | Age | −0.041 | 0.960 | 0.931−0.990 | 0.009 |
| Female | −0.174 | 0.840 | 0.396−1.783 | 0.650 | |
| Overweight | 1.260 | 3.526 | 1.695−7.336 | 0.001 | |
| Obstructive jaundice | −0.087 | 0.917 | 0.382−2.201 | 0.846 | |
| Total bilirubin | −0.001 | 0.999 | 0.997−1.002 | 0.709 | |
| Direct bilirubin | 0.000 | 1.000 | 0.996−1.003 | 0.886 | |
| Previous pancreatitis | −0.039 | 0.961 | 0.277−3.332 | 0.950 | |
| Endoscopic sphincterotomy | −0.220 | 0.803 | 0.391−1.648 | 0.549 | |
| Precut sphincterotomy | 0.875 | 2.398 | 0.845−6.805 | 0.100 | |
| Brush biopsy | −0.290 | 0.749 | 0.299−1.877 | 0.537 | |
| IDUS | −18.970 | 0.000 | 0.000 | 0.999 | |
| Pancreatic stent | −0.014 | 0.986 | 0.429−2.267 | 0.974 | |
| Same-day operation | 0.084 | 1.087 | 0.430−2.752 | 0.860 | |
| Hypertension | 0.1191 | 1.127 | 0.537−2.362 | 0.752 | |
| Pancreatic mass long axis | −0.038 | 0.963 | 0.926−1.001 | 0.057 | |
| Pancreatic mass short axis | −0.065 | 0.937 | 0.892−0.985 | 0.011 | |
| Infection | Age > 60 yr | −0.085 | 0.918 | 0.435−1.938 | 0.823 |
| Overweight | 0.121 | 1.128 | 0.466−2.728 | 0.789 | |
| Proximal biliary obstruction | 1.503 | 4.497 | 0.835−24.205 | 0.080 | |
| Previous PTCD | 0.409 | 1.505 | 0.424−5.341 | 0.527 | |
| Previous ERCP | 0.070 | 1.072 | 0.239−4.818 | 0.927 | |
| Endoscopic sphincterotomy | −0.105 | 0.900 | 0.423−1.919 | 0.786 | |
| Precut sphincterotomy | 0.685 | 1.984 | 0.639−6.156 | 0.236 | |
| Total bilirubin | −0.001 | 0.999 | 0.995−1.002 | 0.372 | |
| Direct bilirubin | −0.001 | 0.999 | 0.995−1.003 | 0.637 | |
| Obstructive jaundice | −0.216 | 0.806 | 0.332−1.954 | 0.633 | |
| Same-day operation | 0.208 | 1.231 | 0.482−3.144 | 0.664 | |
| Hypertension | −0.372 | 0.689 | 0.299−1.591 | 0.383 | |
| Bleeding | Age | −0.031 | 0.970 | 0.923−1.018 | 0.218 |
| Endoscopic sphincterotomy | −0.571 | 0.565 | 0.178−1.789 | 0.332 | |
| Precut sphincterotomy | 1.507 | 4.514 | 1.146−17.779 | 0.031 | |
| Total bilirubin | −0.004 | 0.996 | 0.990−1.002 | 0.183 | |
| Direct bilirubin | −0.005 | 0.995 | 0.988−1.003 | 0.208 | |
| Same-day operation | −0.806 | 0.447 | 0.057−3.528 | 0.445 | |
| Hypertension | 0.387 | 1.472 | 0.457−4.741 | 0.517 |
CI, confidence interval; ERCP, endoscopic retrograde cholangiopancreatography; IDUS, intraductal ultrasonography; OR, odds ratio; PTCD, percutaneous transhepatic cholangiodrainage.
Table 5.
Multivariate logistic regression analysis of postprocedural adverse events.
| Complication | Factors | B value | OR | 95% CI | P value |
|---|---|---|---|---|---|
| Pancreatitis | Hypertension | 0.072 | 1.074 | 0.458−2.521 | 0.869 |
| Total bilirubin | −0.001 | 0.999 | 0.996−1.003 | 0.720 | |
| Age | −0.044 | 0.957 | 0.924−0.991 | 0.014 | |
| Overweight | 1.250 | 3.491 | 1.574−7.744 | 0.002 | |
| Pancreatic mass short axis | −0.086 | 0.918 | 0.868−0.971 | 0.003 | |
| Infection | Hypertension | −0.409 | 0.665 | 0.283−1.560 | 0.348 |
| Total bilirubin | −0.002 | 0.998 | 0.995−1.002 | 0.294 | |
| Pancreatic mass short axis | −0.042 | 0.959 | 0.912−1.008 | 0.102 | |
| Proximal biliary obstruction | 1.447 | 4.252 | 0.769−23.502 | 0.097 | |
| Bleeding | Hypertension | 0.320 | 1.377 | 0.412−4.605 | 0.603 |
| Total bilirubin | −0.004 | 0.996 | 0.990−1.001 | 0.138 | |
| Pancreatic mass short axis | −0.031 | 0.969 | 0.901−1.043 | 0.408 | |
| Precut sphincterotomy | 1.607 | 4.989 | 1.230−20.242 | 0.024 |
CI, confidence interval; OR, odds ratio.
DISCUSSION
Our preliminary findings demonstrate that same-day combined EUS-FNA/B and ERCP procedures are feasible and safe, without compromising endoscopic success rates or increasing postoperative adverse event risks. The same-day cohort exhibited significantly shorter median hospitalization duration, which may translate into substantial reductions in hospitalization costs and optimize healthcare resource utilization while maintaining therapeutic efficacy. In addition, shortening the hospitalization period may have a positive psychological effect on patients. A longer length of hospital stay is a risk factor for anxiety and depression.[10]
Current literature reports a 0%–2% complication rate for EUS-FNA/B in pancreatic solid masses.[11] Our data demonstrate comparable postprocedural pancreatitis rates between the same-day cohort (10%) and stand-alone ERCP (3.5%–9.7%). Similarly, bleeding incidence was equivalent (1.7% vs. 0.35%–9.6%). Notably, the same-day group exhibited significantly higher infection rates (10% vs. 0.5%–3%),[12] potentially attributable to the inclusion of patients with obstructive jaundice or biliary strictures. Biliary stasis from flow obstruction may predispose to cholangitis, consistent with established evidence that hilar obstruction independently predicts post-ERCP cholangitis.[12] Although hilar obstruction showed a nonsignificant trend toward infection risk in our multivariate model, this finding aligns with pathophysiological mechanisms of bile colonization in proximal obstructions.
Our findings demonstrated comparable diagnostic yields of EUS-FNA/B in both cohorts (group A: 80.0%; group B: 84.4%, P = 0.358). While ERCP brushing utilization was 15% and 23.5%, respectively. EUS-guided sampling has become the method of choice for the pathological diagnosis of solid pancreatic masses as it is very accurate (sensitivity and specificity, 85%–89% and 96%–99 %, respectively, according to 3 meta-analyses).[13–15] Weilert et al.[16] demonstrated significantly higher diagnostic sensitivity of EUS-guided sampling compared with ERCP-guided methods in pancreatic mass evaluation (100% vs. 38%, P < 0.001). Currently recommended EUS-FNA/B as the primary diagnostic modality for pancreatic tissue acquisition,[1] while ERCP brushing/biopsy may serve as an adjunctive diagnostic tool in cases requiring concurrent biliary assessment.
Prior studies have demonstrated the safety and efficacy of single-session combined EUS-ERCP interventions for pancreatobiliary diseases. Ascunce et al.[17] conducted a retrospective analysis of 35 patients undergoing same-anesthesia EUS-ERCP, reporting successful biliary stent placement in 96% of ERCP procedures and 96.4% sensitivity of EUS-FNA/B for malignancy detection, with zero procedure-related complications. Purnak et al.[18] retrospectively compared 88 patients with pancreatic ductal adenocarcinoma receiving combined EUS-ERCP with 112 matched controls undergoing separate procedures, finding no significant differences in adverse events and success of procedures. The combined procedure group was associated with a shorter time to initiation of pancreatic ductal adenocarcinoma therapies (mean, 25.2 vs. 42.7 days, P = 0.046).
EUS-FNA/B and ERCP constitute distinct endoscopic modalities. Performing combined EUS-FNA/ERCP efficiently and safely requires careful coordination of resources within any single endoscopy unit. Either a dual-trained operator or readily available separate EUS and ERCP operators are required to perform both segments of the case in a single session. Combined EUS-FNA/B and ERCP performed under single-session anesthesia is associated with a statistically significant prolongation of anesthetic exposure time. A prospective study evaluating rates of anesthesia adverse events during ERCP published by Berzin et al.[19] revealed procedure duration to be a predictor for such events.
Our study innovatively proposes a comparative analysis of same-day versus separate-day EUS-ERCP strategies. This approach circumvents the technical demands of single-operator combined procedures while achieving significant reductions in hospitalization costs and length of stay. In a cohort study by Sbeit et al.[20] involving 61 same-day and 45 separate-day EUS-ERCP cases for choledocholithiasis, no significant differences were observed in anesthetic dosage, procedural duration, or post-ERCP adverse events rate. However, the same-day group demonstrated a reduction in length of stay (7.4 ± 2.9 vs. 9.7 ± 3.9 days, P = 0.0003) and lower hospitalization costs (7680.9 ± 3071.4 vs. 10089.4 ± 4053.4$, P = 0.0003), which aligns with our findings.
In the multivariable analysis of risk factors that identified advancing age (OR: 0.957; 95% CI, 0.924–0.991; P = 0.014) and larger mass short-axis diameter (OR: 0.918; 95% CI, 0.868–0.971; P = 0.003) as independent protective factors against postprocedural pancreatitis, overweight status (body mass index >23.9 kg/m2) emerged as a significant risk factor for pancreatitis (OR: 3.491; 95% CI, 1.574–7.744; P = 0.002). The observed associations may be attributed to an age-related decline in pancreatic exocrine function. Larger mass short-axis diameter potentially reduces technical difficulty through improved targeting depth control. Mechanistically, mass expansion may induce pancreatic parenchymal compression with subsequent atrophy, leading to reduced pancreatic enzyme secretion and consequently lower postprocedural pancreatitis risk. Paradoxically, elevated body mass index, reflecting better nutritional status, correlates with preserved exocrine function, potentially increasing pancreatitis susceptibility. Precut sphincterotomy was independently associated with bleeding risk (OR: 4.989; 95% CI, 1.230–20.242; P = 0.024), which is consistent with the view in the 2019 ESGE guideline that unsuccessful cannulation with precut sphincterotomy is an independent risk factor for bleeding. Post-ERCP bleeding is most frequently seen after biliary endoscopic sphincterotomy, which can be avoided in most cases when biliary stenting is performed.[21] Approximately 96% of the patients underwent biliary stent placement in our study, which might be the reason why we failed to identify endoscopic sphincterotomy as a risk factor for bleeding.
There are some limitations in this study. Study limitations include retrospective design and a potential element of selection bias. Consequently, our data represents experience from a single high-volume tertiary referral center, which may constrain the generalizability of our findings. The absence of longitudinal follow-up precluded a comprehensive assessment of biliary obstruction resolution dynamics, including time-dependent outcomes such as bilirubin normalization and symptom recurrence. This limitation impedes precise comparative effectiveness evaluation between cohorts.
CONCLUSION
Same-day sequential EUS-FNA/B and ERCP demonstrates procedural safety and feasibility, with no significant increase in postoperative adverse events or reduction in technical success rates. This approach significantly reduces hospitalization duration and healthcare costs, while optimizing resource utilization. However, confirmatory evidence from multicenter, prospective randomized controlled trials is required to validate long-term clinical efficacy and safety profiles.
Ethical Statements
The database used in this study was approved by the Medical Ethics Committee of the Shanghai Changhai Hospital (approval number: CHEC2025-200). This is a retrospective analysis and an anonymous character of this study, the need for informed consent was waived by the institutional review board.
Conflicts of Interest
Zhen-Dong Jin is an Associate Editor of the journal; Zhao-Shen Li is an Honorary Editor-in-Chief. The article was subjected to the standard procedures of the journal, with a review process independent of the editor and his research group. The authors declare that they have no financial conflict of interest with regard to the content of this report.
Author contributions
H.Y. Zou analyzed the data and drafted the manuscript. H.Y. Zou, Z.D. Li, J.H. Zhu, Z.D. Jin, Z. Liao, Z.S. Li, Y.Y. Qian, and L. Wang performed the research. H.Y. Zou and Z.D. Li collected data. Y.Y. Qian, and L. Wang designed the research and reviewed and revised the manuscript. All authors have approved the final draft submitted.
Source of Funding
This study was founded by the National Natural Science Foundation of China, No.82170656; No.8257077, and Naval Medical University Affiliated Changhai Hospital under Grant 2024011364.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Funding Statement
This study was founded by the National Natural Science Foundation of China, No.82170656;No.8257077,and Naval Medical University Affiliated Changhai Hospital under Grant 2024011364.
Footnotes
Published online: 20 March 2026
Hong-Yuan Zou and Zheng-Dong Li contributed equally to this article.
References
- 1.Dumonceau JM, Deprez PH, Jenssen C, et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated January 2017. Endoscopy 2017;49(7):695–714. doi:10.1055/s-0043-109021. [DOI] [PubMed] [Google Scholar]
- 2.Facciorusso A, Chandan S, Gkolfakis P, et al. Do biliary stents affect EUS-guided tissue acquisition (EUS-TA) in solid pancreatic lesions determining biliary obstruction? A literature review with meta-analysis. Cancers (Basel) 2023;15(6):1789. doi:10.3390/cancers15061789. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Perone JA, Riall TS, Olino K. Palliative care for pancreatic and periampullary cancer. Surg Clin North Am 2016;96(6):1415–1430. doi:10.1016/j.suc.2016.07.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Stark A, Hines OJ. Endoscopic and operative palliation strategies for pancreatic ductal adenocarcinoma. Semin Oncol 2015;42(1):163–176. doi:10.1053/j.seminoncol.2014.12.014. [DOI] [PubMed] [Google Scholar]
- 5.Balaban EP, Mangu PB, Khorana AA, et al. Locally advanced, unresectable pancreatic cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016;34(22):2654–2668. doi:10.1200/JCO.2016.67.5561. [DOI] [PubMed] [Google Scholar]
- 6.Fisher JM, Gordon SR, Gardner TB. The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma. Pancreas 2011;40(1):21–24. doi:10.1097/MPA.0b013e3181f66e64. [DOI] [PubMed] [Google Scholar]
- 7.Tempero MA, Malafa MP, Basturk O., et al. NCCN guidelines version 2.2025. Pancreatic adenocarcinoma. J Natl Compr Cancer Netw 2025;[cited 2025 Sep 15]:1–94. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. [Google Scholar]
- 8.Lee KH, Kim EY, Cho J, et al. Risk factors associated with adverse events during endoscopic ultrasound-guided tissue sampling. PLoS One 2017;12(12):e0189347. doi:10.1371/journal.pone.0189347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Benjaminov F, Stein A, Lichtman G, Pomeranz I, Konikoff FM. Consecutive versus separate sessions of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis. Surg Endosc 2013;27(6):2117–2121. doi:10.1007/s00464-012-2720-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mirani SH, Areja D, Gilani SS, Tahir A, Pathan M, Bhatti S. Frequency of depression and anxiety symptoms in surgical hospitalized patients. Cureus 2019;11(2):e4141. doi:10.7759/cureus.4141. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Yoshinaga S, Suzuki H, Oda I, Saito Y. Role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis of solid pancreatic masses. Dig Endosc 2011;23(Suppl 1):29–33. doi:10.1111/j.1443-1661.2011.01112.x. [DOI] [PubMed] [Google Scholar]
- 12.Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020;52(2):127–149. doi:10.1055/a-1075-4080. [DOI] [PubMed] [Google Scholar]
- 13.Puli SR, Bechtold ML, Buxbaum JL, Eloubeidi MA. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass? A meta-analysis and systematic review. Pancreas 2013;42(1):20–26. doi:10.1097/MPA.0b013e3182546e79. [DOI] [PubMed] [Google Scholar]
- 14.Hewitt MJ, McPhail MJ, Possamai L, Dhar A, Vlavianos P, Monahan KJ. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: A meta-analysis. Gastrointest Endosc 2012;75(2):319–331. doi:10.1016/j.gie.2011.08.049. [DOI] [PubMed] [Google Scholar]
- 15.Hebert-Magee S, Bae S, Varadarajulu S, et al. The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: A meta-analysis. Cytopathology 2013;24(3):159–171. doi:10.1111/cyt.12071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: Results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80(1):97–104. doi:10.1016/j.gie.2013.12.031. [DOI] [PubMed] [Google Scholar]
- 17.Ascunce G, Ribeiro A, Rocha-Lima C, et al. Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders. Surg Endosc 2010;24(6):1447–1450. doi:10.1007/s00464-009-0798-3. [DOI] [PubMed] [Google Scholar]
- 18.Purnak T, El Hajj II, Sherman S., et al. Combined versus separate sessions of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography for the diagnosis and management of pancreatic ductal adenocarcinoma with biliary obstruction. Dig Dis Sci 2021;66:2786–2794. doi:10.1007/s10620-020-06564-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Berzin TM, Sanaka S, Barnett SR, et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc 2011;73(4):710–717. doi:10.1016/j.gie.2010.12.011. [DOI] [PubMed] [Google Scholar]
- 20.Sbeit W, Kadah A, Shahin A, Khoury T. Same day endoscopic retrograde cholangio-pancreatography immediately after endoscopic ultrasound for choledocholithiasis is feasible, safe and cost-effective. Scand J Gastroenterol 2021;56(10):1243–1247. doi:10.1080/00365521.2021.1955148. [DOI] [PubMed] [Google Scholar]
- 21.Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: Indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy 2018;50(9):910–930. doi:10.1055/a-0659-9864. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.