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   Table of Contents - Current issue
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July-August 2022
Volume 11 | Issue 4
Page Nos. 249-337

Online since Wednesday, August 17, 2022

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EDITORIAL  

Accountability in EUS: Is it possible? p. 249
Pietro Fusaroli
DOI:10.4103/EUS-D-22-00088  
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REVIEW ARTICLES Top

Ultrasound elastography p. 252
Xin-Wu Cui, Kang-Ning Li, Ai-Jiao Yi, Bin Wang, Qi Wei, Ge-Ge Wu, Christoph F Dietrich
DOI:10.4103/EUS-D-21-00151  
Physicians have used palpation as a diagnostic examination to understand the elastic properties of pathology for a long time since they realized that tissue stiffness is closely related to its biological characteristics. US elastography provided new diagnostic information about elasticity comparing with the morphological feathers of traditional US, and thus expanded the scope of the application in clinic. US elastography is now widely used in the field of diagnosis and differential diagnosis of abnormality, evaluating the degree of fibrosis and assessment of treatment response for a range of diseases. The World Federation of Ultrasound Medicine and Biology divided elastographic techniques into strain elastography (SE), transient elastography and acoustic radiation force impulse (ARFI). The ARFI techniques can be further classified into point shear wave elastography (SWE), 2D SWE, and 3D SWE techniques. The SE measures the strain, while the shear wave-based techniques (including TE and ARFI techniques) measure the speed of shear waves in tissues. In this review, we discuss the various techniques separately based on their basic principles, clinical applications in various organs, and advantages and limitations and which might be most appropriate given that the majority of doctors have access to only one kind of machine.
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ORIGINAL ARTICLES Top

Efficacy of EUS-guided needle-based confocal laser endomicroscopy in the diagnosis of pancreatic lesions: A systematic review and meta-analysis Highly accessed article p. 275
Syed Mohsin Saghir, Banreet Singh Dhindsa, Sarav Gunjit Singh Daid, Harmeet S Mashiana, Amaninder Dhaliwal, Chad Cross, Shailender Singh, Ishfaq Bhat, Gordon V Ohning, Douglas G Adler
DOI:10.4103/EUS-D-20-00122  PMID:33666181
Background and Objectives: Needle-based confocal laser endomicroscopy (nCLE) is a procedure in which an AQ-Flex nCLE mini-probe is passed through an EUS-FNA needle into a pancreatic lesion to enable subsurface in vivo tissue analysis. In this study, we conducted a systematic review and meta-analysis of nCLE for the diagnosis of pancreatic lesions. 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 March 2020). The primary outcomes assessed the pooled rate of diagnostic accuracy for nCLE and the secondary outcomes assessed the pooled rate of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and adverse events (AE) of nCLE to diagnose premalignant/malignant pancreatic lesions. Results: Eleven studies on 443 patients were included in our analysis. The pooled rate of diagnostic accuracy of EUS nCLE was 83% (95 confidence interval [CI] = 79–87; I 2 = 0). The pooled rate of sensitivity, specificity, PPV and NPV of EUS nCLE was 85.29% (95% CI = 76.9–93.68; I 2 = 85%), 90.49% (95% CI = 82.24–98.74; I 2 = 64%), 94.15% (95% CI = 88.55–99.76; I 2 = 68%), and 73.44% (95% CI = 60.16–86.72; I 2 = 93%), respectively. The total AE rate was 5.41% (±5.92) with postprocedure pancreatitis being the most common AE at 2.28% (±3.73). Conclusion: In summary, this study highlights the rate of diagnostic accuracy, sensitivity, specificity, and PPV for distinguishing premalignant/malignant lesions. Pancreatic lesions need to be further defined with more validation studies to characterize CLE diagnosis criteria and to evaluate its use as an adjunct to EUS-FNA.
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Usefulness of the automated multiband imaging system for EUS-FNA biopsy specimen evaluation in patients with upper gastrointestinal subepithelial lesions p. 283
Kosuke Okuwaki, Hiroshi Imaizumi, Mitsuhiro Kida, Hironori Masutani, Tomohisa Iwai, Masafumi Watanabe, Kai Adachi, Masayoshi Tadehara, Rikiya Hasegawa, Seigo Nakatani, Takahiro Kurosu, Akihiro Tamaki, Wasaburo Koizumi
DOI:10.4103/EUS-D-21-00143  PMID:35313420
Background and Objectives: Sample isolation processing by stereomicroscopy (SIPS) was recently introduced as an alternative to rapid on-site cytologic evaluation and showed high accuracy for use in pathologic diagnoses. SIPS is a useful, but slightly complicated procedure; therefore, a new, more straightforward method for the objective estimation of the core tissue amount required during the sampling is desirable. We evaluated the usefulness of the automated multiband imaging system (AMUS) for calculating whitish core amounts in EUS-FNA biopsy (EUS-FNAB) samples from patients with subepithelial lesions (SELs). Methods: Four EUS-FNAB specimens per patient were obtained from 20 patients with upper gastrointestinal SELs. The correlation between the whitish core amount calculated by AMUS, length of the manually measured whitish cores (stereomicroscopically visible white core [SVWC]), and sample suitability for pathologic evaluation were analyzed. Results: We identified 13 patients with gastrointestinal stromal tumors, five with leiomyomas, one with a schwannoma, and one with an ectopic pancreas. The histological diagnostic accuracy was 100%, median SVWC length was 9 mm, and median whitish core area, calculated using AMUS, was 10 mm2. SVWC length correlated with whitish core amount (ρ = 0.81, P < 0.01) and adequacy score (ρ = 0.54, P < 0.01). Whitish core amount correlated with adequacy score (ρ = 0.54, P < 0.01). The area under the receiver-operating characteristic curve calculated for whitish core amount with respect to the histological diagnosis was 0.83 (P < 0.01; cutoff ≥4 mm2, sensitivity 98.4%). Conclusions: AMUS, a simple on-site verification instrument, is an alternative to SIPS for determining the appropriate SEL tissue sampling quantity with high diagnostic accuracy.
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A preferable modality for the differentiation of peripancreatic fluid collections: Endoscopic ultrasound p. 291
Ning Xu, Longsong Li, Danqi Zhao, Zixin Wang, Xueting Wang, Runzi Wang, Yanbo Zeng, Lei Zhang, Ning Zhong, Ying Lv, Enqiang Linghu, Ningli Chai
DOI:10.4103/EUS-D-21-00130  PMID:35083982
Background and Objectives: Peripancreatic fluid collections (PFCs), including walled-off necrosis (WON) and pancreatic pseudocysts (PPCs), are categorized by imaging modalities, including EUS, computed tomography (CT), and magnetic resonance imaging. Our study aimed to evaluate the effectiveness of EUS in differentiating PFCs compared with that of other modalities. Subjects and Methods: Data were collected retrospectively from 99 patients at fourteen centers who were recruited to undergo lumen-apposing metal stent placement to treat PFCs. Results: PFCs were detected by CT and EUS in 51 WON and 48 PPC patients. The accuracy in differentiating PFCs by EUS was much higher than that of CT (90.9% vs. 50.5%, P < 0.001). The accuracy in identifying WON on EUS was much higher than that on CT (82.4% vs. 13.7%, P < 0.001), while the accuracy in identifying PPC was comparable in these two modalities (89.6% vs. 100%, P > 0.05). WON patients required more times of debridement than PPC patients (P < 0.001). Conclusion: EUS can categorize symptomatic PFCs with higher accuracy than CT and is a preferred imaging modality to detect solid necrotic debris.
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EUS-guided drainage of the pancreatic duct for the treatment of postoperative stenosis of pancreatico-digestive anastomosis or pancreatic duct stenosis complicating chronic pancreatitis: Experience at a tertiary care center p. 296
Franz Rudler, Fabrice Caillol, Jean-Philippe Ratone, Christian Pesenti, Jean-Christophe Valats, Alexei Soloveyv, Marc Giovannini
DOI:10.4103/EUS-D-21-00150  PMID:35083983
Background and Objectives: For the treatment of pancreatic duct stenosis due to chronic pancreatitis (CP) or postoperative (PO) stenosis, endoscopic procedures are usually the first choice. In cases of failure of the recommended treatment by ERCP, anastomosis between the Wirsung duct and the stomach or duodenum can be performed under EUS guidance. The objective of this retrospective study was to compare the outcomes of pancreatico-gastric or pancreaticoduodenal anastomosis under EUS for PO stenosis versus CP stenosis. Subjects and Methods: This was a retrospective, single-center, consecutive case study of patients who underwent EUS-guided Wirsungo-gastric/bulbar anastomosis. Results: Forty-three patients were included. Twenty-one patients underwent treatment for PO stenosis, and 22 patients underwent treatment for CP stenosis. The technical success rate was 95.3% (41/43), with 100% in cases of PO stenosis and 90.9% in cases of CP stenosis. The clinical success rate was 72.5% (29/40): 75% (15/20) in cases of PO stenosis and 70% (14/20) in cases of CP stenosis. The overall morbidity rate was 34.9% (15/43). The main complication was postprocedural pain, occurring in 20.9% (9/443) of patients. The rate of stent migration or obstruction was 27.9% (12/43). There was no difference in patient outcomes or morbidity according to the etiology of the stenosis. The median follow-up duration in this study was 14 months. Conclusions: EUS-guided Wirsungo-gastric/duodenal anastomosis is a feasible, minimally invasive, safe, and relatively effective procedure. The rates of technical success, clinical success, and complications were not different between patients with PO and CP stenosis. However, the follow-up period was too short to assess recurrent symptoms in these patients.
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Accuracy and clinical outcomes of pancreatic EUS-guided fine-needle biopsy in a consecutive series of 852 specimens p. 306
Mikkel Marschall Thomsen, Michael Hareskov Larsen, Tina Di Caterino, Gitte Hedegaard Jensen, Michael Bau Mortensen, Sönke Detlefsen
DOI:10.4103/EUS-D-21-00180  
Background and Objectives: Pancreatic EUS-guided fine needle biopsy (EUS-FNB) is increasingly used. Accuracy of EUS-FNB, particularly for benign diseases, utility of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and complication rate are not fully elucidated. We evaluated operating characteristics of EUS-FNB overall and for different diagnostic categories, value of additional EUS-FNB if malignancy is suspected but initial diagnosis is inconclusive, and frequency and type of complications. Methods: A retrospective tertiary single-center study including 852 consecutive pancreatic SharkCore EUS-FNBs from 723 patients between 2015 and 2020. EUS-FNB diagnoses were applied according to Papanicolaou Society's system and each category was further subcategorized. Results: Sufficient tissue cylinders for a histologic diagnosis were obtained in 93.4% (796/852). Accuracy was overall, for malignant, and benign entities 85.6% (confidence interval [CI]: 83.2%–87.9%), 88.3% (CI: 85.9%–90.4%), and 94% (CI: 92.2%–95.5%). Sensitivity and accuracy of EUS-FNB for autoimmune pancreatitis (AIP) (n = 15) was 83.3% (CI: 58.6%–96.4%) and 99.2% (CI: 98.3%–99.7%). Of patients in whom malignancy was suspected but initial EUS-FNB diagnosis was inconclusive, 7.3% (53/723) underwent one or two additional EUS-FNBs, and in 54.7% (29/53) of these, a malignant diagnosis was established. The frequency of hospitalization following EUS-FNB was 4.7%, with 0.2% (n = 2) incidents needing active intervention. Conclusions: We found a high accuracy of pancreatic EUS-FNB across all diagnostic categories including rare entities, such as AIP. In patients with a clinical suspicion of malignancy, additional EUS-FNB resulted in a conclusive diagnosis in more than half of cases. Complications necessitate hospitalization in almost 5%, but the majority are self-limiting.
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B2 puncture with forward-viewing EUS simplifies EUS-guided hepaticogastrostomy (with video) p. 319
Nozomi Okuno, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Yasuhiro Kuraishi, Masahiro Tajika, Tsutomu Tanaka, Sachiyo Onishi, Keisaku Yamada, Daiki Fumihara, Takafumi Yanaidani, Sho Ishikawa, Masanori Yamada, Tsukasa Yasuda, Moaz Elshair
DOI:10.4103/EUS-D-21-00154  PMID:35848655
Background and Objectives: EUS-guided hepaticogastrostomy (EUS-HGS) is in widespread use; however, there are few dedicated devices. The B2 route is technically easier than the B3 route for guidewire insertion, dilation, and stenting but if performed with conventional oblique-viewing (OV) EUS, B2 puncture can cause transesophageal puncture and severe adverse events. The aim of this study was to assess the efficacy of forward-viewing (FV) EUS, which we have developed to improve safety for B2 puncture in EUS-HGS (B2-EUS-HGS). Patients and Methods: This single-center retrospective study included 61 consecutive patients who underwent B2-EUS-HGS with FV between February 2020 and March 2021 at Aichi Cancer Center, Japan. The patients were prospectively enrolled, and clinical data were retrospectively collected for these 61 cases. Results: The overall technical success rate of EUS-HGS was 98.3% (60/61). The rate of EUS-HGS with FV was 95.0% (58/61) after three cases converted to OV, and that of B2-EUS-HGS with FV was 88.5% (54/61). The early adverse event rate was 6.5% (4/61). There were no instances of transesophageal puncture. Median procedure time was 24 min (range, 8–70), and no patient required cautery dilation. Conclusions: B2-EUS-HGS can be performed safely using FV, without transesophageal puncture, and supportability of the device is improved as FV is coaxial with the guidewire. FV was efficacious in B2-EUS-HGS, which shows promise for clinical application in the future.
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IMAGES AND VIDEOS Top

A rare case of multifocal intraductal nodules and a solid mass of the pancreas p. 325
Jun Li, Yilong Wang, Feng Liu
DOI:10.4103/EUS-D-21-00076  PMID:34755705
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EUS-guided hepaticogastrostomy and antegrade direct peroral cholangioscopy: An effective alternative to overcome the distance (with video) p. 327
Alessandro Fugazza, Roberto Gabbiadini, Mauro Sollai, Marco Spadaccini, Alessandro Repici, Andrea Anderloni
DOI:10.4103/EUS-D-21-00087  PMID:34755707
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Balloon guidewire technique during EUS-guided hepaticogastrostomy p. 330
Akihisa Ohno, Toyoma Kaku, Nao Fujimori
DOI:10.4103/EUS-D-21-00067  PMID:34755704
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Epstein–Barr virus-associated gastric carcinoma diagnosed by EUS-guided fine needle biopsy (with video) p. 332
Jun Nishikawa, Seiji Kaino, Atsushi Goto, Eijiro Harada, Isao Sakaida
DOI:10.4103/EUS-D-21-00026  PMID:34494584
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Immunoglobulin G4-related cholecystitis mimicking gallbladder cancer diagnosed by EUS-guided biopsy p. 334
Kosuke Nagai, Masaki Kuwatani, Yunosuke Takishin, Ryutaro Furukawa, Hajime Hirata, Kazumichi Kawakubo, Tomoko Mitsuhashi, Naoya Sakamoto
DOI:10.4103/EUS-D-21-00028  PMID:34494585
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LETTERS TO EDITOR Top

EUS-guided therapy of nonvariceal refractory bleeding: A prospective observational study p. 336
Laura Uribarri-González, Guillermo Pérez-Aguado, Amaia Arrubla Gamboa, Juan J Vila
DOI:10.4103/EUS-D-21-00169  
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