To compare the adequacy of balanced propofol sedation (BPS) and general anaesthesia (GA) for endoscopic ultrasonography-guided tissue acquisition (EUS-TA) of solid pancreatic lesions.

This is a single-center, controlled cohort study with retrospective analysis of a prospectively collected database including all patients who underwent EUS-TA for diagnosis of a solid pancreatic mass at the gastrointestinal endoscopy unit in a tertiary referral cancer center. According to our institutional protocol, all ERCP is performed under GA. Many patients with pancreatic masses present with jaundice, thus requiring endoscopic biliary drainage, and it is common for ERCP and EUS to be indicated concomitantly. Patients who underwent ERCP and EUS on the same day under general anaesthesia as well as some cases in which EUS was performed alone but under intubation were analysed in the GA group.All procedures were performed by advanced fellows under the direct supervision of expert endoscopists. The material obtained was subsequently analysed by a pathologist specialising in the gastrointestinal tract. However, the pathologist was not present in the endoscopy room during the procedure, i.e., there was no rapid on-site evaluation (ROSE). The sample was considered adequate if sufficient material was obtained for histological interpretation, and inadequate if sufficient cells were absent or if aspirates contained only blood or gastrointestinal epithelial cells. The final diagnosis was based on histology or clinical/radiological follow-up.

From April 2013 to February 2025, a total of 491 EUS-guided pancreatic punctures were conducted on 433 patients, of whom 50.3% were female. Overall, 85.7% (95% CI 82.3–88.6%) of the samples were considered adequate. Three hundred sixty-three (73.9%) received BPS, ninety-three (18.9%) received GA, twenty-six (5.3%) were sedated by an anaesthetist (AS), and sedation data was not available for nine procedures (1.8%). The demographic and lesion characteristics did not differ between groups. Adequacy was 84.3% (95% CI 80.6–88.0%) in the BPS group, 89.2% (95% CI 83.0–95.2%) in the GA group, and 89.7% (95% CI 78.8–100%) in AS procedures (p = 0.202). Comparing only BPS and GA also did not achieve statistical significance (p = 0.223). Comparison of endoscopist (BPS) versus anaesthetist (GA+AS) similarly showed no statistically significant difference (p = 0.175).

To the best of our knowledge, this real-world cohort study comprising 491 EUS-TA procedures for solid pancreatic lesions represents the largest single-centre series directly comparing BPS with GA and AS regimens. This study conveys a clear message: endoscopist-administered BPS is as effective as GA and AS for EUS-TA.

Although a minor numerical difference was observed, GA does not confer any meaningful advantage in terms of adequacy. While patient immobility is undeniably superior under GA, this does not result in increased efficacy for obtaining adequate samples when experienced endoscopists perform sedation with propofol. Thus, mandating GA for all pancreatic EUS-TA procedures is unwarranted, even in the context of training fellows in EUS-TA.

BPS directed by trained endoscopists must remain the standard of care. GA should be reserved selectively for high-risk patients and concomitant ERCP. In summary, in a contemporary real-world setting, endoscopist-administered BPS delivered an adequacy equivalent to GA for EUS-TA of solid pancreatic lesions. Further studies evaluating adverse event rates, recovery time, and cost-effectiveness are needed to strengthen these findings.