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   Table of Contents - Current issue
Coverpage
September-October 2020
Volume 9 | Issue 5
Page Nos. 277-353

Online since Thursday, October 15, 2020

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EDITORIAL  

EUS-guided radiofrequency ablation: Where we are? p. 277
Hussein Hassan Okasha, Yehia M Naga, Mohammad El Sherbiny
DOI:10.4103/eus.eus_33_20  PMID:32655083
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COMMENTARY Top

EUS-guided therapy of gastric varices (with video) p. 280
Carlos Robles-Medranda, Roberto Oleas, Raquel Del Valle, Kenneth F Binmoeller
DOI:10.4103/eus.eus_55_20  PMID:32913153
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REVIEW ARTICLES Top

Do we need elastography for EUS? p. 284
Christoph F Dietrich, Sean Burmeister, Stephan Hollerbach, Paolo Giorgio Arcidiacono, Barbara Braden, Pietro Fusaroli, Michael Hocke, Julio Iglesias-Garcia, Masayuki Kitano, Alberto Larghi, Bertrand Napoleon, Kofi W Oppong, Mihai Rimbas, Adrian Saftoiu, Anand V Sahai, Siyu Sun, Yi Dong, Silvia Carrara, Joo Ha Hwang, Christian Jenssen
DOI:10.4103/eus.eus_25_20  PMID:32675464SS
We recently introduced a series of papers “What should be known prior to performing EUS exams.” In Part I, the authors discussed which clinical information and whether other imaging modalities are needed before embarking EUS examinations. In Part II, technical controversies on how EUS is performed were discussed from different points of view. In this article, important practical issues regarding EUS elastography will be raised and controversially discussed from very different points of view.
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How to perform EUS-guided tattooing? p. 291
Mihai Rimbas, Alberto Larghi, Pietro Fusaroli, Yi Dong, Stephan Hollerbach, Christian Jenssen, Adrian Săftoiu, Anand V Sahai, Bertrand Napoleon, Paolo Giorgio Arcidiacono, Barbara Braden, Sean Burmeister, Silvia Carrara, Xin Wu Cui, Michael Hocke, Julio Iglesias-Garcia, Masayuki Kitano, Kofi W Oppong, Siyu Sun, Milena Di Leo, Maria Chiara Petrone, Anthony Y B Teoh, Christoph F Dietrich
DOI:10.4103/eus.eus_44_20  PMID:32883923
Recently, we introduced a series of papers describing on how to perform certain techniques and controversies in EUS. In the first paper, “What should be known before performing EUS examinations, Part I,” the authors discussed clinical information and whether other imaging modalities should be needed before embarking in EUS examination. In Part II, some technical controversies on how EUS is performed are discussed from different points of view by providing the relevant available evidence. Herewith, we describe on how to perform EUS-guided fine needle tattooing (FNT) in daily practice. The aim of this paper is to discuss pros and cons for several issues including historical remarks, injecting material, technical approach, and how to perform EUS-FNT including argues in favor and against.
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Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: A systematic review and meta-analysis p. 298
Gaurav Kakked, Habeeb Salameh, Antonio R Cheesman, Nikhil A Kumta, Satish Nagula, Christopher J DiMaio
DOI:10.4103/eus.eus_10_20  PMID:32655080
EUS-guided biliary drainage (EUS-BD) has been used as a salvage modality for relief of malignant biliary obstruction (MBO) after a failed ERCP. Multiple recent randomized controlled trials (RCTs) and observational studies have been published to assess the suitability of EUS-BD as a first-line modality for achieving palliative BD. We aimed to perform a systematic review and meta-analysis comparing primary EUS-BD versus ERCP for MBO. We searched PubMed, Medline, and Embase up to January 1, 2019, to identify RCTs and observational studies evaluating the efficacy and safety of primary EUS-BD (without a prior attempted ERCP) versus ERCP. Quality of RCTs and observational studies was assessed using Jadad and Newcastle–Ottawa scores, respectively. The outcomes of interest were technical success, clinical success, odds of requiring a repeat intervention, and procedure-related adverse events. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. Meta-analysis was performed using the random effects model in RevMan 5.3 (the Cochrane Collaboration, the Nordic Cochrane Centre, Copenhagen, Denmark). Five studies (three RCTs and two observational studies) with 361 patients were included. Both procedures achieved comparable technical success (OR: 1.20 [0.44–3.24], I2 = 0%) and clinical success (OR: 1.44, confidence interval [CI]: 0.63–3.29, I2 = 0%). The overall adverse outcomes (OR: 1.59 [0.89–2.84]) did not differ between the two groups. In the ERCP group, 9.5% of patients developed procedure-related pancreatitis versus zero in the EUS group (risk difference = 0.08%, P = 0.02). There was no statistically significant difference in nonpancreatitis-related adverse events. The odds of requiring reintervention for BD (1.68 [0.76–3.73], I2 = 42%) did not differ significantly. The ERCP group had significantly higher odds of requiring reintervention due to tumor overgrowth (5.35 [1.64–17.50], I2 = 0%). EUS-BD has comparable technical and clinical success to ERCP and can potentially be used as a first-line palliative modality for MBO where expertise is available. ERCP-related pancreatitis which can cause significant morbidity can be completely avoided with EUS.
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ORIGINAL ARTICLES Top

Exploration of an effective training system for the diagnosis of pancreatobiliary diseases with EUS: A prospective study p. 308
Chaoqun Han, Chi Nie, Xiaoping Shen, Tao Xu, Jun Liu, Zhen Ding, Xiaohua Hou
DOI:10.4103/eus.eus_47_20  PMID:32913147
Background and Objective: There are limited data on multistage-based training programs focused on EUS. We aimed to explore an effective training system for diagnosing pancreaticobiliary diseases with EUS. Materials and Methods: Nine advanced endoscopy trainees (AETs) with less EUS experience from nine institutions were recruited. The training system consisted of multiple stages and multi-teaching methods, including biliopancreatic standard scanning, anatomy and imaging knowledge, simulator, hands-on operations, error correction, and case analysis over a 12-month training period. Grading for technical and cognitive skills was assessed using The EUS Skills Assessment Tool. Results: After training, the overall scores for radial (4.16 ± 0.21 vs. 1.46 ± 0.16, P < 0.01) and linear (4.43 ± 0.20 vs. 1.63 ± 0.23, P < 0.01) scanning were significantly improved. The aortopulmonary window/mediastinum station can be learned more easily by AETs compared with other stations (P = 0023). The scanning of the descending part of the duodenum seemed to improve the slowest after training (P = 0.0072), indicating that the descending part of the duodenum can be more difficult and should be the focus of training. Every teaching method heightened EUS competence, especially case analysis and hands-on operations. AETs achieved equivalent EUS competence after training despite their initial experience. Through a poststudy questionnaire, it was found that all AETs strongly agreed they were satisfied with the training system, and their confidence was greatly enhanced when EUS was performed independently. Conclusions: The current multistage and multi-methods training system showed efficient performance in the cognitive and technical competence of EUS. Descending part of duodenum scanning was difficult for beginners and should be the focus of training.
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An international, multi-institution survey on performing EUS-FNA and fine needle biopsy p. 319
Jintao Guo, Anand V Sahai, Anthony Teoh, Paolo Giorgio Arcidiacono, Alberto Larghi, Adrian Saftoiu, Ali A Siddiqui, Brenda Lucia Arturo Arias, Christian Jenssen, Douglas G Adler, Sundeep Lakhtakia, Dong-Wan Seo, Fumihide Itokawa, Marc Giovannini, Girish Mishra, Luis Sabbagh, Atsushi Irisawa, Julio Iglesias-Garcia, Jan Werner Poley, Juan J Vila, Lachter Jesse, Kensuke Kubota, Evangelos Kalaitzakis, Mitsuhiro Kida, Mohamed El-Nady, Sh Untaro Mukai, Takeshi Ogura, Pietro Fusaroli, Peter Vilmann, Praveer Rai, Nam Q Nguyen, Ryan Ponnudurai, Chalapathi Rao Achanta, Todd H Baron, Ichiro Yasuda, Hsiu-Po Wang, Jinlong Hu, Bowen Duan, Manoop S Bhutani, Siyu Sun
DOI:10.4103/eus.eus_56_20  PMID:32883921
Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and fine needle biopsy (FNB) are effective techniques that are widely used for tissue acquisition. However, it remains unclear how to obtain high-quality specimens. Therefore, we conducted a survey of EUS-FNA and FNB techniques to determine practice patterns worldwide and to develop strong recommendations based on the experience of experts in the field. Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS Task Force (ISEUS-TF). The survey was administered by E-mail through the SurveyMonkey website. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. Another questionnaire about the level of recommendation was designed to assess the respondents' answers. Results: ISEUS-TF members developed a questionnaire containing 17 questions that was sent to 53 experts. Thirty-five experts completed the survey within the specified period. Among them, 40% and 54.3% performed 50–200 and more than 200 EUS sampling procedures annually, respectively. Some practice patterns regarding FNA/FNB were recommended. Conclusion: This is the first worldwide survey of EUS-FNA and FNB practice patterns. The results showed wide variations in practice patterns. Randomized studies are urgently needed to establish the best approach for optimizing the FNA/FNB procedures.
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EUS and EUS-guided FNA/core biopsies in the evaluation of subepithelial lesions of the lower gastrointestinal tract: 10-year experience p. 329
Irina M Cazacu, Ben S Singh, Adriana A Luzuriaga Chavez, Pramoda Koduru, Shamim Ejaz, Brian R Weston, William A Ross, Jeffrey H Lee, Sinchita Roy-Chowdhuri, Manoop S Bhutani
DOI:10.4103/eus.eus_51_20  PMID:32913150
Background and Objective: The widespread use of colonoscopy has led to an increasing number of subepithelial lesions (SELs) being detected in the lower gastrointestinal (GI) tract. This study aimed to analyze the utility of EUS and its role in the management of lower GI SELs. Patients and Methods: Records of all patients who were referred for lower EUS evaluation of a SEL at a tertiary center between 2007 and 2018 were retrospectively reviewed after IRB approval. Data collection included patient/lesion characteristics, technical details of procedure, and pathology results. Results: A total of 47 patients underwent EUS examinations for the evaluation of 49 suspected SEL in the lower GI tract (2 patients had 2 SELs each). Out of the 49 suspected lesions, the most frequent location was in the rectum (30/49, 61.2%). EUS showed extraluminal compression in 2 cases (2/49, 4.1%) and intraluminal lesions were identified in 40 cases (40/49, 81.6%). In 7 patients (7/49, 14.3%), no lesion could be identified by EUS. Twenty (20/49, 40.8%) SELs were malignant or had malignant potential. Twenty-six EUS-guided fine-needle aspirations (FNAs) and 14 EUS-core biopsies were performed. EUS-FNA alone was able to correctly diagnose 15/26 (57.7%) of the lower SELs. When EUS-guided fine needle biopsies (FNB) were performed during the same procedure, the final diagnosis was confirmed in 21/26 (80.8%) cases. There was only one procedure-related complication caused by use of narcotics. Conclusion: EUS-guided FNA/FNB are feasible and safe techniques for assessing lower GI SELs and provide valuable information regarding lesion characteristics and their malignant potential with high diagnostic accuracy.
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EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography p. 337
Diana Wee, Stephanie Izard, Gregory Grimaldi, Kara L Raphael, Tai-Ping Lee, Arvind J Trindade
DOI:10.4103/eus.eus_57_20  PMID:33106466
Background and Aims: Guidelines recommend either EUS or magnetic resonance cholangiopancreatography (MRCP) for intermediate risk of choledocholithiasis. There is a lack of evidence that supports proceeding with EUS if the MRCP is negative and if clinical suspicion still exists. Methods: This is a retrospective study of all patients who underwent EUS to assess for choledocholithiasis at a tertiary care referral center from July 2013 to October 2019. Results: A total of 593 patients underwent EUS for evaluation for choledocholithiasis. Of the 593 patients, 35.2% (209/593) had an MRCP. 73.2% (153/209) had a negative MRCP while 26.8% (56/209) had a positive MRCP. Of the group of patients who underwent EUS with a negative MRCP, 15% (23/153) were positive for choledocholithiasis on EUS. Of these, 91% (21/23) were also positive for sludge or stones on endoscopic retrograde cholangiopancreatography and thus 14% (21/153) of the EUS were “true positives.” There were no clinical or laboratory factors predictive of choledocholithiasis on univariate analysis in the EUS plus negative MRCP group. When further analyzing the MRCP negative group into MRCP-/EUS+ and MRCP-/EUS-subgroups, a total bilirubin >3 mg/dL predicted a bile duct stone (55% vs. 32%, P = 0.05). Conclusion: The diagnostic yield of EUS for suspected choledocholithiasis in the setting of a negative MRCP is 14% in our cohort. EUS should be considered in patients with intermediate risk of choledocholithiasis with a negative MRCP if the clinical suspicion is still present, and especially if the total bilirubin is above 3 mg/dL.
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IMAGES AND VIDEOS Top

EUS-guided gastrogastrostomy and gastroduodenal stenting for gastric cancer after Roux-en-Y gastric bypass (with video) p. 345
Gaetan-Romain Joliat, Anna Dayer, Nicolas Garin, Domenico Galasso
DOI:10.4103/eus.eus_53_20  PMID:32883922
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Intraductal papillary mucinous neoplasms from a pancreas rest (with video) p. 347
Xiaohong Wang, Hong Ye, Juncheng Wu, Yugang Xu, Huanling Shi, Xiaopei Li, Ning Zhong, Haipeng Yuan
DOI:10.4103/eus.eus_54_20  PMID:32913152
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LETTERS TO EDITOR Top

Safety and efficacy of EUS-guided drainage of liver abscess: A single-center experience p. 350
Surinder Singh Rana, Soburuddin Ahmed, Ravi Sharma, Rajesh Gupta
DOI:10.4103/eus.eus_41_20  PMID:32719200
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Why is EUS-guided cyst-gastrostomy more common than cyst-duodenostomy: A disease state or endoscopist preference p. 352
Moamen M Gabr, Taylor Frost, Praneeth Kudaravalli, Gregory S Bills, Shista Priyadarshini, Stephanie McDonough, Douglas G Adler
DOI:10.4103/eus.eus_39_20  PMID:32687072
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