Optimizing management strategies for pancreatic cystic lesions using confocal laser endomicroscopy The pancreatic cystic lesions (PCLs) have varying degrees of malignant potential and may cause compressive symptoms. Lauromacrogol ablation has been proven to be safe and efficacious for the treatment of PCLs, but it has strict indications. Evaluating whether a cyst is suitable for ablation relies on cyst fluid analysis and biopsy results obtained from an initial diagnostic puncture. However, this entails a subsequent therapeutic puncture for patients who are eligible for ablation. Confocal laser endomicroscopy provides intraoperative diagnosis of pancreatic cystic pathology and determines suitability for concomitant ablation. Our study demonstrated that confocal laser endomicroscopy identified lesions suitable for concomitant ablation with 86% diagnostic accuracy, higher than that of traditional intraoperative cyst morphology. Furthermore, the incidence of postoperative acute pancreatitis was 6.9%, and all instances were mild in severity. Therefore, due to its favorable intraoperative diagnostic performance, confocal laser endomicroscopy serves as a valuable tool for optimizing the management strategy of patients with pancreatic cystic lesions.

Led by Xinwei Hao and Ningli Chai, the research enrolled 29 PCL patients who underwent concurrent EUS-guided fine-needle aspiration (EUS-FNA) and nCLE. The core goal was to evaluate nCLE’s ability to distinguish concomitant ablation-eligible lesions (CAELs) from ablation-ineligible lesions (CAILs) intraoperatively, and compare its diagnostic performance to traditional EUS morphology and cyst fluid string sign assessments

—————Key Insights—————

nCLE outperforms traditional EUS-based diagnosis 

nCLE achieved an 86% overall diagnostic accuracy for identifying CAELs, with a 94% sensitivity and 77% specificity—significantly higher than the 66% accuracy of EUS morphology/string sign (p=0.039). The nCLE procedure was also efficient, with a mean duration of just 4.61 minutes, and enabled real-time visualization of PCL microstructures (e.g., SCN’s “fern pattern” vascular network, intraductal papillary mucinous neoplasm [IPMN]’s finger-like papillae) at 1000-fold magnification, delivering “virtual biopsies” during puncture. 

Favorable safety profile 

The overall adverse event (AE) rate was 13.8%, with only 6.9% of patients developing mild acute pancreatitis (per revised Atlanta classification). No severe AEs (e.g., intracystic hemorrhage, infection, fluorescein allergy) were reported, and all AEs resolved with conservative symptomatic treatment.

Effective LA outcomes with single-session care 

13 of 15 patients deemed CAELs by nCLE underwent immediate LA (2 declined ablation). Among 8 patients with 10 months of mean follow-up, 37.5% achieved complete cyst resolution, 25% partial resolution, and median cyst volume dropped significantly from 7537 mm³ to 1113 mm³ (p<0.05). Critically, nCLE eliminated the need for repeat punctures by enabling diagnostic assessment and treatment decision-making in a single EUS-FNA session.

—————Clinical Significance————— 

Traditional PCL diagnosis relies on post-procedural cyst fluid analysis and biopsy—requiring a second puncture for eligible patients, which increases trauma, healthcare costs, and procedural risk. nCLE’s realtime imaging capability addresses this major limitation, providing detailed visualization of cyst epithelium, vascular patterns, and malignant features to accurately classify PCLs intraoperatively. Notably, nCLE complements EUS by overcoming morphological diagnostic pitfalls (e.g., distinguishing SCN from BD-IPMN, assessing pancreatic duct communication). While nCLE has minor limitations (e.g., reliance on 19-G needles, potential ambiguity between MCN and IPMN microstructures), integrating nCLE with EUS findings further improves lesion classification for ablation eligibility. For clinical practice, nCLE-guided LA streamlines PCL management: it reduces unnecessary repeat procedures, supports shared decision-making for select SCN patients (e.g., symptomatic lesions, patient preference), and maintains the safety of LA—an already low-risk alternative to surgery for benign PCLs. 

—————Summary————— 

This study establishes nCLE as a valuable adjunctive tool for PCL management, with excellent real-time diagnostic performance that enables accurate, single-session assessment of LA eligibility. By combining the minimally invasive benefits of EUS-guided LA with nCLE’s intraprocedural precision, clinicians can optimize PCL care—reducing patient harm, improving treatment efficiency, and advancing the field of interventional gastroenterology for pancreatic lesions.