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   Table of Contents - Current issue
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January-February 2021
Volume 10 | Issue 1
Page Nos. 1-78

Online since Thursday, February 11, 2021

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EDITORIAL  

Controversies in EUS p. 1
Christoph F Dietrich
DOI:10.4103/EUS-D-21-00024  
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REVIEW ARTICLES Top

Diagnostic value of endobronchial ultrasound image features: A specialized review Highly accessed article p. 3
Xinxin Zhi, Junxiang Chen, Fangfang Xie, Jiayuan Sun, Felix J. F. Herth
DOI:10.4103/eus.eus_43_20  PMID:32719201
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) technology is important in the diagnosis of intrathoracic benign and malignant lymph nodes (LNs). With the development of EBUS imaging technology, its role in noninvasive diagnosis, as a supplement to pathology diagnosis, has been given increasing attention in recent years. Many studies have explored qualitative and quantitative methods for the three EBUS modes, as well as a variety of multimodal analysis methods, to find the optimal method for the noninvasive diagnosis using EBUS for LNs. Here, we review and comment on the research methods and predictive diagnostic value, discuss the existing problems, and look ahead to the future application of EBUS imaging.
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EUS-through-the-needle microbiopsy forceps in pancreatic cystic lesions: A systematic review Highly accessed article p. 19
Vasile Daniel Balaban, Irina M Cazacu, Larisa Pinte, Mariana Jinga, Manoop S Bhutani, Adrian Saftoiu
DOI:10.4103/eus.eus_23_20  PMID:32611848
Pancreatic cystic lesions (PCLs) are being increasingly encountered in clinical practice, and sometimes, they can represent a diagnostic challenge. Recently, a through-the-needle micro forceps biopsy (MFB) device was introduced in the endosonography practice to facilitate EUS-guided sampling of PCLs. The aim was to perform a systematic review of studies evaluating the technical aspects, safety, and efficacy of the EUS-guided MFB for PCLs. A literature search was performed in three major databases, PubMed, Embase, and Web of Science in September 2019 using the search terms: “through-the-needle,” “biopsy forceps,” “microforceps,” “endoscopic ultrasound,” and “endosonography.” Case reports and case series with <10 patients were excluded from the analysis. Altogether nine studies reporting on 463 patients were included in our systematic review. The mean age of the patients was 68.3 years, with a slight female predominance (60.9%). Most of the cysts were located in the body/tail of the pancreas (61.2%), with an overall mean size of 33 mm. The technical success of EUS-guided MFB was reported in 98.5%. The tissue acquisition yield reported was 88.2%, and the diagnostic accuracy was 68.6%. Adverse events were reported in 9.7%. EUS-guided MFB is technically feasible, safe, and has a high diagnostic accuracy for PCLs.
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EUS and ERCP: A rationale categorization of a productive partnership p. 25
Juan J Vila, Iñaki Fernández-Urién, Juan Carrascosa
DOI:10.4103/eus.eus_58_20  PMID:33353903
ERCP and EUS are complementary techniques in the management of biliary and pancreatic diseases. Combination of these two techniques can reach different levels of complexity with increasing rates of adverse events. In this article we propose a categorization of the relationship between EUS and ERCP based on whether EUS indicates, complements, facilitates or replaces ERCP. It has implications for the complexity of the technique, the training of the endoscopist and the necessary hospital resources. This classification can also be useful in planning endoscopist training and patient management.
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ORIGINAL ARTICLES Top

EUS-guided transanastomotic drainage for severe biliopancreatic anastomotic stricture using a forward-viewing echoendoscope in patients with surgically altered anatomy p. 33
Tomohisa Iwai, Mitsuhiro Kida, Hiroshi Yamauchi, Kosuke Okuwaki, Toru Kaneko, Rikiya Hasegawa, Masafumi Watanabe, Takahiro Kurosu, Hiroshi Imaizumi, Wasaburo Koizumi
DOI:10.4103/eus.eus_72_20  PMID:33473043
Background and Objectives: Balloon enteroscopy-assisted ERCP (BE-ERCP) has become the first-line therapy for biliopancreatic anastomotic strictures. However, it is not always successful, and salvage methods have not been established. This study aimed to evaluate the outcomes of EUS-guided transanastomotic drainage using a forward-viewing (FV) echoendoscope. Patients and Methods: Of eight cases wherein BE-ERCP treatment failed due to severe or complete benign anastomotic stricture, seven cases underwent EUS-guided choledochojejunostomy, and EUS-guided pancreaticojejunostomy was applied in one case after intubating an FV echoendoscope into the anastomotic site. Results: The success rate of reaching the target site was 100% (8/8) for patients after modified Child resection. The median time to reach the anastomosis was 5 min (range: 3–17 min), and the technical success rate for drainage was 75% (6/8). The median total procedure time was 33.5 min (range: 22–45 min) for six successful cases. Cautery dilatation catheters were necessary to dilate the puncture site in all cases, and no early complications were observed. During the follow-up period (median: 13.3 months [range: 6.5–60.3]), recurrence of the stricture occurred in one case, and a stent-free status was achieved after 6–12 months of stent placement in five cases. Conclusions: EUS-guided transanastomotic drainage using an FV echoendoscope is a feasible and safe rescue technique for the management of benign severe biliopancreatic anastomotic strictures.
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An international study of interobserver variability of “string sign” of pancreatic cysts among experienced endosonographers p. 39
Seifeldin Hakim, Emmanuel Coronel, Graciela M. Nogueras González, Philip S Ge, Suresh T Chari, Nirav Thosani, Srinivas Ramireddy, Ricardo Badillo, Tomas DaVee, Marc F Catalano, Robert J Sealock, Sreeram Parupudi, Lyndon V Hernandez, Virendra Joshi, Atsushi Irisawa, Surinder Rana, Sundeep Lakhtakia, Peter Vilmann, Adrian Saftoiu, Siyu Sun, Marc Giovannini, Matthew H Katz, Michael P Kim, Manoop S Bhutani
DOI:10.4103/eus.eus_73_20  PMID:33473044
Background and Objectives: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the “string sign” test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. Methods: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: “Is the string sign positive?” and “If the string sign is positive, what is the length of the formed string?” Also asked “What is the cutoff length for string sign to be considered positive?” Interobserver variability was assessed using the kappa statistic (κ). Results: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. Conclusion: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.
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Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures p. 51
Jérôme Winkler, Fabrice Caillol, Jean-Philippe Ratone, Erwan Bories, Christian Pesenti, Marc Giovannini
DOI:10.4103/eus.eus_68_20  PMID:33402550
Background and Objectives: EUS-guided biliary drainage (EUS-BD) has emerged as a complementary technique for primary drainage or as a rescue technique after failed endoscopic retrograde cholangiography. The objective of this study was to demonstrate the feasibility of EUS-BD for malignant hilar stenosis (MHS), both as an initial and rescue procedure. Patients and Methods: This study was a retrospective work based on a prospective registry of patients with malignant drainage stenosis of the hilum. For this analysis, only patients who underwent EUS-BD drainage were included. The drainage procedure could be performed by EUS-BD alone or in combination with another technique, for initial drainage or reintervention. Results: Between January 2015 and September 2018, 20 patients were included. The mean patient age was 68 years. Seven patients had primary liver tumors and 13 had obstructions caused by metastasis. Four patients had Type II stenosis, 7 had Type IIIA, 2 had Type IIIb, and 7 had Type IV stenosis. Sixteen patients underwent EUS-guided hepaticogastrostomy (EUS-HGS) for initial drainage and four as reintervention. For initial drainage, 2 patients underwent EUS-HGS alone and 14 underwent EUS-HGS in combination with another technique: 11 combined with endoscopic retrograde cholangiopancreatography (ERCP), 2 with percutaneous transhepatic drainage, and 1 with ERCP and percutaneous transhepatic drainage. The technical success rate for EUS-HGS in the drainage of MHS was 100%, and the clinical success rate was 95%. The mean percentage of liver drained was 84%, with an average 1.7 endoscopic sessions and an average 2.7 protheses. The early complication rate was 35% and the mortality rate was 5%. Five EUS-HGS/ERCP combination drainage procedures were performed in one session and six were performed in two sessions with similar complication rates and percentages of liver segments drained. Conclusion: EUS-BD is a feasible and safe technique for initial drainage and for reintervention procedures. The EUS-HGS/ERCP combination seemed to be useful in cases of complex stenosis and could be performed during the same session or in two sessions.
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A randomized noninferiority trial comparing the diagnostic yield of the 25G ProCore needle to the standard 25G needle in suspicious pancreatic lesions p. 57
Galab M Hassan, Jonathan M Wyse, Sarto C Paquin, Gilles Gariepy, Roula Albadine, Benoît Mâsse, Helen Trottier, Anand V Sahai
DOI:10.4103/eus.eus_69_20  PMID:33402551
Background and Objectives: The aim of the study was to perform the first randomized trial comparing the diagnostic yield, bloodiness, and cellularity of the 25G standard needle (25S) and the 25G ProCore™ needle (25P). Materials and Methods: All patients referred to the tertiary care referral center for EUS guided fine-needle aspiration (EUS-FNA) of suspicious solid pancreatic lesions were eligible. EUS-FNA was performed in each lesion with both 25S and 25P needles (the choice of the first needle was randomized), using a multipass sampling pattern, without stylet or suction. Rapid on-site evaluation was used when possible. Pap-stained slides were read by a single experienced cytopathologist, blinded to the needle type. Results: One hundred and forty-three patients were recruited. Samples were positive for cancer in 122/143 (85.3%) with the 25S needle versus 126/143 (88.1%) with the 25P needle, negative in 17/143 (11.9%) with the 25S needle versus 13/143 (9.1%) with the 25P needle, and suspicious in 4/143 (2.8%) with each needle. There was no difference in any outcome based on the type of the first needle. No carryover effect was detected (P = 0.214; NS). Cumulative logistic regression analyses showed no associations between the type of needle and diagnostic yield for cancer, cellularity, or bloodiness. The difference in the yield for cancer was 2.9% (−4.2; 10.1%); with the confidence interval upper within the predetermined noninferiority margin of 15%. Conclusion: The 25S needle is noninferior to the 25P needle for diagnosing cancer in suspicious pancreatic lesions.
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Optimal number of needle passes during EUS-guided fine-needle biopsy of solid pancreatic lesions with 22G ProCore needles and different suction techniques: A randomized controlled trial p. 62
Wei Zhou, Shi-Yu Li, Hui Jiang, Li Gao, Jun Li, Xiang-Yu Kong, Li Yang, Ai-Qiao Fang, Zhen-Dong Jin, Kai-Xuan Wang
DOI:10.4103/EUS-D-20-00147  
Background and Objectives: The sensitivity of EUS-guided fine-needle biopsy (EUS-FNB) varies considerably. The optimal number of passes through a solid pancreatic lesion with a 22G FNB needle during EUS-FNB is controversial. This prospective randomized controlled study aimed to determine the optimal number of needle passes during EUS-FNB of solid pancreatic lesions, with 22G FNB needles and different sampling techniques. Methods: Pancreatic masses were sampled using 22G FNB needles with either the stylet slow-pull (SP) technique or the standard-suction (SS) technique. We determined the number of needle passes required to obtain a diagnostic accuracy of >90%. Differences between the two techniques in terms of technical success rate, cytological acquisition, core tissue acquisition, sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and complications were analyzed. Results: A total of 120 patients were randomly assigned to either SP or SS group. Three patients who were lost to follow-up and one who did not complete 5 passes due to bent needle head were excluded from the study. Fifty-six cases in the SP group and 60 cases in the SS group were included in the analysis. For SP technique, the cumulative accuracy of passes 1, 2, 3, 4, and 5 was 44.83%, 76.79%, 87.50%, 92.86%, and 94.64%, respectively. For SS technique, the cumulative accuracy of passes 1, 2, 3, 4, and 5 was 71.67%, 85.0%, 90.0%, 93.33%, and 95.0%, respectively. For each group, there was no statistically significant difference in accuracy after 3 and 4 passes. After 4 passes, the pooled sensitivity (92.59% vs. 93.10%), accuracy (92.86% vs. 93.10%), and specificity (100% vs. 100%) were similar (P > 0.05) in the SP and SS groups, respectively. In addition, positive cytological diagnoses (83.9% vs. 85.0%) and positive histological diagnoses (71.4% vs. 78.3%) were comparable (P > 0.05) in the SP and SS groups, respectively. No statistically significant factor was found associated with diagnostic sensitivity for each group. Conclusion: When on-site cytological evaluation is unavailable, we recommend that at least 3 passes with 22G ProCore needles be performed during EUS-FNB using the SS technique, at least 4 passes when using SP technique. The SS technique showed potential advantages over SP technique in tissue acquisition and diagnostic capabilities.
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IMAGES AND VIDEOS Top

EUS-FNA of portal venous tumoral thrombosis for diagnosis of hepatocellular carcinoma without primary hepatic mass (with video) p. 71
Ludivine Gan, Fanny Houser, Thomas Di Bernardo, Aude Le Goffic, Philippe Ah-Soune
DOI:10.4103/eus.eus_64_20  PMID:33402548
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Delayed gastric bleeding after EUS-guided fine-needle aspiration of autoimmune pancreatitis p. 73
Wen Shi, Shengyu Zhang, Hui Xu, Yunlu Feng, Aiming Yang
DOI:10.4103/eus.eus_74_20  PMID:33402552
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A rare cause of upper gastrointestinal bleeding from a submucosal tumor p. 75
Johanna Reinecke, Ahmad Amanzada, Florian Elger, Michael Ghadimi, Albrecht Neesse
DOI:10.4103/eus.eus_75_20  PMID:33402553
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LETTERS TO EDITOR Top

EUS-guided drainage of pancreatic fluid collections during COVID-19 pandemic p. 77
Surinder Singh Rana, Vipin Koushal, Rajesh Gupta, Navin Pandey
DOI:10.4103/eus.eus_66_20  PMID:33402549
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