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   Table of Contents - Current issue
Coverpage
May-June 2021
Volume 10 | Issue 3
Page Nos. 151-226

Online since Wednesday, June 16, 2021

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EDITORIAL  

EUS-directed transgastric ERCP: A first-line option for ERCP following Roux-en-Y gastric bypass p. 151
Monique T Barakat, Douglas G Adler
DOI:10.4103/eus.eus_148_20  
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REVIEW ARTICLES Top

EUS-guided biliary drainage for malignant hilar biliary obstruction: A concise review p. 154
Sridhar Sundaram, Vinay Dhir
DOI:10.4103/EUS-D-21-00004  
EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP for distal biliary obstruction in expert hands. Various routes for EUS-guided access in distal biliary obstruction include EUS choledochoduodenostomy, EUS-guided rendezvous, and EUS-antegrade (EUS-AG) stent placement. While percutaneous transhepatic biliary drainage and ERCP are established modalities in management of malignant hilar biliary obstruction, the role of EUS-BD is emerging. Various methods of drainage in hilar obstruction include EUS hepaticogastrostomy, EUS hepaticoduodenostomy, EUS-guided bridging stent placement, and combined ERCP and EUS-guided biliary drainage. In this review, we discuss the role of EUS-BD in malignant hilar biliary obstruction with the currently available evidence, along with the limitations and challenges to the use of this modality in management of these patients.
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Practical approach to linear EUS examination of the liver p. 161
Hussein Hassan Okasha, Mahmoud Farouk, Ramy Ibrahim El Hendawy, Rasha Mohamed Mahmoud, Ahmed El-Meligui, Hassan Atalla, Ahmed Morad Hashim, Katarzyna M Pawlak
DOI:10.4103/EUS-D-20-00162  PMID:33904508
EUS has become a substantial diagnostic and therapeutic modality for digestive tract conditions. The extent of endosonographic assessment is wide, and, among others, it allows for the evaluation of liver anatomy and related pathologies. Moreover, EUS assessment has proved more accurate in detecting small focal liver lesions missed by standard imaging examinations such as computed tomography or magnetic resonance. Endosonographically, various liver segments can be visualized by transgastric and transduodenal scanning following anatomical landmarks, thus providing arranged systematic examination. In addition, knowledge considering the correct position during examination is crucial for EUS-guided procedures such as hepaticogastrostomy, ablation of tumors, and measurement of portal pressure gradient. The evolution of EUS-guided intervention has contributed to the increasing importance of understanding the hepatic segmental anatomy during the EUS examination.
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TRAINING COURSE Top

General principles of image optimization in EUS p. 168
Malay Sharma, Stephan Hollerbach, Pietro Fusaroli, Axel Löwe, Jonas Koch, André Ignee, Christian Jenssen, Christoph F Dietrich
DOI:10.4103/eus.eus_80_20  PMID:33666178
With the development of modern EUS, multiple imaging functions, transducer settings, and examination modes have become available for clinical settings. While the major determinants of the ultrasound beam are still comprised of the signal wavelength, its frequency range, and its amplitude, other modifications and calculations have gained more interest for advanced users, such as tissue harmonic imaging (THI), spatial and frequency compounding, certain versions of speckle reduction, and various Doppler/duplex settings. The goal of such techniques is a better, perhaps more realistic image, with reduced artifacts (such as speckle), better image contrast, and an improved signal-to-noise ratio. In addition, “add-ons” such as THI, which is based on the phenomenon of nonlinear distortion of acoustic signals as they travel through tissues, provide greater contrast and an enhanced spatial resolution than conventional EUS. Finally, optimization of spectral and color Doppler imaging in EUS requires experience and knowledge about the basic principles of Doppler/duplex phenomena. For these purposes, factors such as adjustment of Doppler controls, Doppler angle, color gain, spectral wall filters, and others require special attention during EUS examinations. Incorporating these advanced techniques in EUS examinations may be time-consuming and cumbersome. Hence, practical guidelines enabling endosonographers to steer safely through the large quantity of technological properties and settings (knobology) are appreciated. This review provides an overview of the role of important imaging features to be adjusted before, during, and after EUS procedures.
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ORIGINAL ARTICLES Top

EUS-guided pelvic drainage: A systematic review and meta-analysis p. 185
Banreet Singh Dhindsa, Yassin Naga, Syed Mohsin Saghir, Amaninder Dhaliwal, Daryl Ramai, Chad Cross, Shailender Singh, Ishfaq Bhat, Douglas G Adler
DOI:10.4103/eus.eus_71_20  PMID:33463556
Background and Objectives: EUS-guided pelvic abscess drainage (EUS-PAD) is a procedure that utilizes an echoendoscope to visualize an area of interest for needle insertion and placement of a stent, catheter, or both for drainage of the target abscess. The aim of this study was to perform a systematic review and meta-analysis for the safety and efficacy of EUS-PAD. Materials and Methods: We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to February 2020). The primary outcomes for this study were the technical and clinical success of EUS-PAD. The secondary outcomes assessed for this study were adverse events of the procedure and subgroup analysis of individual adverse events. Results: Eight studies with a total of 135 patients combined were included in our analysis. The rate of technical success was 100% and the calculated pooled rate of clinical success was 92% (95% confidence interval [CI]: 87%, 98%; P = 0.31; I2 = 15%). The calculated pooled rate of adverse events was 9.4% (±17.9%), with stent migration (5.5 ± 18.06%) being the most common adverse event. Conclusion: EUS-PAD offers a viable alternative that can minimize the need for surgical intervention in the drainage of pelvic abscesses. EUS-PAD has also demonstrated long-term clinical success with an acceptable rate of complications.
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Urgent and early EUS-guided biliary drainage in patients with acute cholangitis p. 191
Shuntaro Mukai, Takao Itoi, Atsushi Sofuni, Takayoshi Tsuchiya, Kentaro Ishii, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Kenjiro Yamamoto, Kazumasa Nagai, Yukitoshi Matsunami, Yasutsugu Asai, Takashi Kurosawa, Hiroyuki Kojima, Toshihiro Homma, Hirohito Minami, Yuichi Nagakawa
DOI:10.4103/eus.eus_70_20  PMID:33463555
Background and Objectives: EUS-guided biliary drainage (EUS-BD) has been reported as an effective alternative drainage technique. However, clinical data on EUS-BD for patients with acute cholangitis (AC) are limited. The aim of this study was to analyze the clinical outcomes of EUS-BD in patients with AC. Patients and Methods: Nineteen patients with AC who underwent urgent or early drainage (within 96 h) by EUS-guided hepaticoenterostomy (EUS-HES) between January 2014 and November 2019 were retrospectively reviewed. Furthermore, the clinical outcomes of EUS-HES using a plastic stent in the AC group (n = 15) were compared to those in the non-AC group (n = 88). Results: In the 19 AC cases, the technical and clinical success rate was 100% with 5.3% of moderate adverse events (biliary peritonitis [n = 1]). Regarding the comparison between the AC group and the non-AC group, the clinical success rate was 100% in both groups and the adverse event rate was not statistically significantly different (P = 0.88). Although the recurrent biliary obstruction (RBO) rate was not statistically significantly different (P = 0.43), the early RBO rate was statistically significantly higher in the AC group (26.7% vs. 3.4%, P < 0.001). Kaplan–Meier curves showed that AC was associated with a shorter time to RBO (P = 0.046). The presence of AC was found to be an independent risk factor of early RBO (odds ratio = 10.3; P = 0.005). Conclusions: Urgent or early biliary drainage (within 96 h) by EUS-BD can be a feasible and safe alternative procedure for patients with AC, although there is a tendency of early RBO.
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A new needle-based confocal laser endomicroscopy pattern of malignant pancreatic mucinous cystic lesions (with video) p. 200
Yunlu Feng, Xiaoyan Chang, Yu Zhao, Dong Wu, Zhilan Meng, Xi Wu, Tao Guo, Qingwei Jiang, Shengyu Zhang, Qiang Wang, Aiming Yang
DOI:10.4103/eus.eus_35_20  PMID:32655084
Background and Objectives: The diagnosis of malignant pancreatic cystic lesions (PCLs) remains challenging. Needle-based confocal laser endomicroscopy (nCLE) is an emerging promising imaging technique capable of real-time in vivo microscopic imaging of the cyst wall. We aimed to develop and validate a new nCLE diagnostic criteria for malignant mucinous cystic lesions (MLs). Methods: Patients referred for EUS-FNA of indeterminate PCLs with at least one worrisome features according to Fukouka consensus were consecutively prospectively enrolled from July 2016 to July 2018. The final diagnosis was based on surgical histology, cytopathology, or committee consensus. Five investigators nonblindly reviewed nCLE features and identified potential diagnostic feature for malignant MLs, which was also reviewed in histology imaging accordingly. Furthermore, the nCLE diagnostic feature was evaluated with an independent nCLE dataset by two investigators in a double-blind manner. Results: A nCLE pattern of dark aggregates of neoplastic cells was identified as diagnostic for MLs, which was consistent with histological findings of irregular branching and budding in malignant MLs. An independent validation revealed that the accuracy, sensitivity, and specificity of this feature for the diagnosis of malignant MLs were 94%, 75%, and 100%, respectively. Conclusion: The new nCLE criterion is promising for diagnosis of malignant MLs which warrants further confirmation in large cohort.
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Histopathological evaluation of needle tract seeding caused by EUS-fine-needle biopsy based on resected specimens from patients with solid pancreatic masses: An analysis of 73 consecutive cases p. 207
Ryosuke Nakatsubo, Kenjiro Yamamoto, Takao Itoi, Atsushi Sofuni, Takayoshi Tsuchiya, Kentaro Ishii, Reina Tanaka, Ryosuke Tonozuka, Shuntaro Mukai, Kazumasa Nagai, Hiroshi Yamaguchi, Yuichi Nagakawa
DOI:10.4103/EUS-D-20-00174  PMID:33586689
Background and Objectives: EUS-guided fine-needle biopsy (EUS-FNB) is considered a safe and useful method for preoperative diagnosis of resectable solid pancreatic masses. However, needle tract seeding (NTS) after EUS-FNB has recently been reported, which may affect long-term outcome. The aim of this study was to evaluate NTS after EUS-FNB. Materials and Methods: We reviewed 73 resected cases that underwent preoperative EUS-FNB for a pancreatic tumor from April 2014 to March 2016 and evaluated the utility and adverse events of EUS-FNB based on consecutively resected pathological specimens. Results: The final diagnoses were pancreatic ductal adenocarcinoma (n = 67), neuroendocrine neoplasm (n = 5), and acinar cell carcinoma (n = 1). The diagnostic accuracy of preoperative EUS-FNB was 98.6%. Clinical adverse events were observed in 4.1% of cases (bleeding, n = 2; acute pancreatitis, n = 1) and abnormal pathological findings in 4.1% (NTS, n = 2; acute focal pancreatitis, n = 1). Conclusions: Although EUS-FNB is useful for preoperative diagnosis of pancreatic tumors, we may need to reconsider the risk of NTS and use of EUS-FNB in patients with a resectable solid pancreatic mass unless the tract itself is planned to be resected.
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IMAGES AND VIDEOS Top

Single-session EUS-guided gastroenterostomy and hepaticogastrostomy using dedicated metal stents (with videos) p. 214
Andrea Anderloni, Alessandro Fugazza, Marco Spadaccini, Matteo Colombo, Roberto Gabbiadini, Licia Vanessa Siracusano, Tiziana Pressiani, Alessandro Repici
DOI:10.4103/eus.eus_60_20  PMID:33463553
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Contrast enhanced EUS for evaluation of mural nodule in pancreatic cystic neoplasm (with video) p. 216
Surinder Singh Rana, Rajesh Gupta
DOI:10.4103/EUS-D-20-00260  PMID:34003140
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EUS-guided splenic abscess drainage using lumen apposing metal stent p. 219
Ahmed Mohamed Elmeligui, Ameya Deshmukh, Hussein Hassan Okasha, Nasim Parsa, Javier Tejedor-Tejada, Jose Nieto
DOI:10.4103/EUS-D-20-00262  PMID:33975989
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EUS-guided gastroenterostomy in a COVID-19-infected patient with duodenal stenosing lymphoma (with videos) p. 221
Gemma Rossi, Maria Chiara Petrone, Giuseppe Vanella, Livia Archibugi, Paolo Giorgio Arcidiacono
DOI:10.4103/EUS-D-20-00255  PMID:33885002
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LETTER TO THE EDITOR Top

Usefulness of EUS-FNA with contrast-enhanced harmonic imaging for diagnosis of gallbladder tumor p. 224
Takashi Tamura, Yasunobu Yamashita, Masahiro Itonaga, Reiko Ashida, Masayuki Kitano
DOI:10.4103/EUS-D-20-00112  PMID:33586687
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