Background: Different types of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) techniques are used in clinical practice; the best method in terms of outcome is not standardized. Objectives: To compare diagnostic adequacy of aspirated material, cytopathologic and EUS morphological features among capillary action, suction, and no suction FNA methods. Methods: A prospective, single-blinded, randomized study was conducted at a tertiary care hospital. A total of 37 patients were excluded, and a total of 300 (100 in each arm) patients were included. Patients were randomized into the three groups, i.e., capillary action (Group 1), suction (Group 2), and no suction (Group 3). Results: A total of 300 patients (195 males) underwent EUS-guided FNA of 235 lymph nodes and 65 pancreatic masses (distribution not statistically different among groups); mean age was 52 ± 14 years. A 22-gauze needle (93%) was used in majority. There was no statistically difference among all the groups regarding lymph node size at large axis and ratio, type of needle, echo-features, echogenicity, calcification, necrosis, shape, borders (lymph nodes), number of passes, and cellularity. Diagnostic adequacy of the specimen was 91%, 91%, and 94% in Groups 1, 2, and 3, respectively (P = 0.665). The suction group had significantly more number of slides and more hemorrhagic slides in comparison to other groups. Conclusion: EUS-guided FNA by capillary action, suction, and no suction methods has similar diagnostic adequacy of specimen; suction method has disadvantage of more number of slides and more hemorrhagic slides.!

Background and Objectives: A large part of the liver is now accessible for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), but there are limited data in the literature evaluating efficacy and safety of the technique. Patients and Methods: We performed a 5-year review of all EUS-FNAs performed in primitive and secondary hepatic lesions. Results were shown as mean (range) and statistics were calculated as per-protocol or intention-to-treat (ITT) analyses. Results: A total of 152 patients (81 males/71 females), with a mean age of 63 years (35–86), with 158 lesions were examined either for primitive masses (n = 50) or for metastases (n = 102). Sensitivity for malignancy was 96% and 91%, specificity 100 and 100%, positive predictive value 100 and 100%, and negative predictive value 40% and 22% in the per-protocol and ITT analyses, respectively. Results were significantly better (P < 0.05) in secondary versus primitive masses. Liver EUS-FNA provided diagnosis in ten patients without evident primary location and in four pancreatic adenocarcinomas without contributive pancreatic FNA. The 25-gauge needles were significantly less sensitive (P < 0.01) than 22- or 19-gauge needles. Lesions with a smaller size and hilar location (P < 0.01) were more frequently associated with false negative results. Bleeding was the sole complication observed in 3% of patients, mainly in primitive lesions, and statistically associated with histology needles (P < 0.001). Conclusions: EUS-FNA in the liver is highly sensitive for the diagnosis of malignancy in primitive and secondary masses and is helpful in determining the primary origin of liver metastases. Histology needles might be preferred for diagnosis, but their used was associated with a small but significant increase of bleeding.

Background: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with cytological analysis is widely used for tissue acquisition of intra-abdominal mass; however, it can be challenging when differentiating types of malignancy is needed due to limited tissue quantity. Cellblock preparation offers histologic assessment, but the data on its usefulness are scarce. Objectives: To assess the diagnostic accuracy of combined cytology and cellblock obtained from EUS-FNA. Methods: Patients with intra-abdominal mass undergoing EUS-FNA were identified. Both cytology and cellblock specimens were reviewed by a gastrointestinal cytopathologist. Results: A total of 166 patients were recruited. Of these, 75% had malignancy and 25% had inflammatory/reactive lesions. The mean size of lesions was 2.5 cm. Specimen adequacy was 79% for cytology and 78% for cellblock. Cytology had sensitivity of 68.5% (95% confidence interval [CI], 58.9–77.1), specificity of 95.7% (95% CI, 78.1–99.9), positive predictive value (PPV) of 98.7% (95% CI, 92.7–00), and negative predictive value (NPV) of 39.3% (95% CI, 26.4–53.4) with area under the receiver operating characteristic curve (AUROC) 0.821 (95% CI, 0.744–0.882). Cellblock had sensitivity of 65.4% (95% CI, 55.2–74.5), specificity of 96% (95% CI, 79.6–99.9), PPV of 98.5% (95% CI, 92–100), NPV of 40.7% (95% CI, 26.4–53.4) with AUROC 0.807 (95% CI, 0.727–0.872). The diagnostic performance of combined cytology and cellblock was superior to either one alone (P < 0.05) as demonstrated by an improvement of sensitivity to 74.6% (95% CI, 65.4–82.4) while maintaining specificity of 96% with AUROC 0.853 (95% CI, 0.782–0.908). Conclusions: The combination of cytology and cellblock increases the diagnostic accuracy of EUS-FNA. This approach shows a promise in practice where on-site pathology is not available.

Background and Objectives: The role of endoscopic ultrasound (EUS)-guided fiducial marker insertion to guide radiotherapy for esophageal cancer is uncertain. The aim of this study is to evaluate the optimal method of performing the technique. Methods: This was a retrospective study of all patients who received EUS-guided fiducial marker insertion between March 2015 and November 2016. Gold fiducial markers of size 5 mm × 0.35 mm (VISICOIL, IBA Dosimetry, USA) were placed under EUS guidance either intratumorally or in the normal submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, migration rates, and tumor response rates. Results: During the study period, 25 patients received the procedure. The mean (standard deviation [S.D.]) age was 59.6 (10.2) years. The mean (S.D.) length and volume of the tumor were 6.7 (4.2) cm and 24.6 (15.8) ml, respectively, and 88% of the patients had Stage 3 disease. Twenty patients had markers inserted by endobronchial ultrasound (EBUS) and 60% in the submucosa. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly, more fiducials had early (42.9% vs. 0%, P = 0.017) and late migration (100% vs. 0%, P < 0.001) in the intratumoral group. There were no differences in the stage of disease (P = 0.657), percentage of patients who completed radiotherapy (P = 0.299), and response rate (P = 0.515). Conclusions: In obstructing esophageal carcinomas, fiducial markers should be placed in the submucosa just proximal and distal to the tumor by EBUS.

Background: In patients with undiagnosed peritoneal lesions, diagnostic laparoscopy is often required for tissue diagnosis. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is another possible approach but has never been prospectively evaluated. Objectives: To study the efficacy of EUS-FNA for avoiding diagnostic laparoscopy in patients with peritoneal lesions. Methods: From December 2015 to October 2016, 18 consecutive patients with peritoneal lesions were enrolled. Diagnostic laparoscopy was planned if pathological result of EUS-FNA was negative. Results: Computed tomographic findings were soft tissue nodules/mass deposit in the peritoneum (n = 13; 72.2%), ascites (n = 12; 66.7%), omental cake appearance (n = 6; 33.3%), and stranding of mesentery (n = 3; 16.7%). Two benign cases were pancreatic ascites confirmed by laparoscopy and peritoneal tuberculosis confirmed by successful treatment. EUS-FNA showed positive results of malignancy in 14/18 patients (77.8%) and 28/54 passes (51.8%). Of 28 passes with positive results, 22/28 (78.6%) and 6/28 (21.4%) were obtained from hypoechoic and hyperechoic lesions, respectively. No adverse events were observed. Of four patients with negative results of EUS-FNA, two patients underwent diagnostic laparoscopy showing multiple omental and peritoneal nodules from metastatic stomach cancer (n = 1) and pancreatic ascites (n = 1) and another two patients refused laparoscopy; one had advanced staged pancreatic cancer with poor performance status and another was clinically diagnosed as peritoneal tuberculosis with successful treatment. The sensitivity and specificity of EUS-FNA were 87.5% and 100%, respectively. Diagnostic laparoscopy can be avoided in 14/18 (77.8%) patients. Conclusions: In this prospective study, EUS-FNA has a high sensitivity rate for diagnosing causes of peritoneal lesions and can avoid diagnostic laparoscopy in majority of patients.

Background and Objectives: The role of endoscopic ultrasound (EUS) with contrast agents is accepted in clinical use for diagnostic imaging. We evaluated usefulness of contrast-enhanced harmonic EUS (CEH-EUS)-guided fine-needle aspiration (FNA) for hepatic lesions. Methods: A total of 30 consecutive patients with hepatic mass underwent CEH-EUS-FNA between September 2010 and November 2016. Results: Twenty-eight patients (93.3%) had malignant tumors whereas two patients (6.7%) had benign hepatic masses. Technical success rate was 100%. Obtained sample was adequate in 93.3% (28/30). The median tumor size on EUS and number of needle passes were 24.5 mm (interquartile range [IQR] 14.5–40.8) and 2 (IQR 2–3), respectively. Before contrast enhancement, 80% of hepatic lesions (24/30) were identified on B-mode. After contrast enhancement, 93.3% of hepatic lesions (28/30) were distinguished from liver parenchyma on contrast harmonic mode. Diagnostic accuracy for hepatic mass was 92.9%. There were no procedure-related complications. Conclusions: CEH-EUS-FNA can be a safe and efficient method for the diagnosis of hepatic mass. It can increase the diagnostic accuracy in the setting of poorly visible hepatic lesions.

Background: Linear endoscopic ultrasound (EUS) evaluation of pancreaticobiliary (PB) system usually requires scanning from both stomach and duodenum. Feasibility of assessing the complete PB system from stomach alone has not been studied. Objectives: To conceptualize and evaluate a system-based approach (railroad approach) for linear PB-EUS, by which the PB anatomy could be assessed from the stomach itself. Methods: Three maneuvers were conceptualized and evaluated (alpha maneuver for stomach and sigma and xi maneuvers for duodenum). The maneuvers were prospectively evaluated in 100 consecutive patients requiring PB-EUS. Results: The three maneuvers could be completed in a median time of 12 min (range 8-22 min). Median total procedure time was significantly higher than that for alpha maneuver alone (12 vs. 6 min, P = 0.0001). The visualization rates of hilum and common hepatic duct (100% vs. 83.5%, P = 0.0001) were significantly higher from the stomach than from the duodenum. The visualization rates of retropancreatic common bile duct (CBD) (97.6% vs. 100%, P = 0.49), uncinate process (100% vs. 100%), and pancreatic duct (98.8% vs. 100%, P = 1.0) did not differ significantly if patients with pancreatic head calcifications were excluded. There was no significant difference in the clinical diagnosis made from the stomach versus that made from the duodenum, after excluding body and tail lesions (head of the pancreas neoplasms 100% vs. 100%, CBD stone 100% vs. 84.6% [P = 0.75], pancreatic cysts 83.3% vs. 83.3%, respectively). Conclusions: Adequate anatomical and diagnostic information of the PB system may be acquired by EUS scanning from the stomach in significantly shorter procedure time.

Background and Objectives: Endoscopic ultrasonography (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) patterns for diagnosing mucinous pancreatic cystic lesions (PCLs) have been recently validated. The aim of this study was to compare the accuracy of EUS-nCLE to the standard of care for differentiating mucinous from nonmucinous PCLs. Methods: In a prospective study evaluating EUS-nCLE, fluid from 59 PCLs was analyzed by carcinoembryonic antigen (CEA), cytology, and next generation sequencing (NGS). The final diagnosis of PCLs was based on surgical histopathology (n = 36 [61%]) or clinical diagnosis based on imaging features, specific NGS results, follow-up >1 year, and/or resolution of PCL (n = 23 [39%]). Diagnostic indices and area under receiver operator curve (ROC) of different modalities were computed for all subjects. Results: Among the 59 subjects (31 females; mean age 59.4 years), 36 cysts were mucinous and 23 nonmucinous. The ROC analyses associated with the detection of patterns of “epithelial bands/papillae” for mucinous PCLs demonstrated the greatest area under the curve (96%). The sensitivity, specificity, and accuracy of nCLE were significantly greater than the accuracy of CEA, cytology, and combination of CEA/cytology (P < 0.001). When the study population was restricted to those with surgical histopathology (n = 36; mucinous 26 [72%]), diagnostic accuracy of nCLE for mucinous PCLs continued to be higher than the combination of CEA/cytology (94% vs. 67%, P = 0.006). Conclusions: Among the current diagnostic modalities, EUS-nCLE detection of “epithelial bands or papillae” is more accurate than the current “standard of care” for the differentiation of mucinous from nonmucinous PCLs. These preliminary results warrant further validation in larger, multicenter studies.

Background and Objectives: Preoperative portal vein embolization (PVE) by percutaneous transhepatic approach has been performed in candidates of major liver resection including right hepatectomy and extended right hepatectomy. This procedure can increase volume of remnant liver and prevent postoperative hepatic failure. The aim of this animal study is to evaluate the technical feasibility and safety of endoscopic ultrasonography (EUS)-guided intrahepatic PVE. Methods: EUS-guided intrahepatic PVE with coil and histoacryl was performed in seven pigs under general anesthesia using linear array echoendoscope. The intrahepatic portal vein (PV) was punctured with a 19-gauge FNA needle, and an embolization coil was inserted into the selected intrahepatic PV. Then, histoacryl was injected through the same FNA needle. The blood flow change in the selected intrahepatic PV was evaluated by color Doppler EUS. After 1-week observation period, necropsy was performed. Results: Embolization coil was placed in the selected intrahepatic PV successfully in six of seven animals, and Histoacryl injection was successful in five of them. In one case, histoacryl injection was failed due to needle deflection and early clogging. After coil insertion and histoacryl injection, disappearance of blood flow in the treated intrahepatic PV was confirmed by color Doppler. There was no adverse event in six animals during 1-week observation period. Necropsy revealed no evidence of damage to the treated intrahepatic PV and intra-abdominal organs. Conclusions: EUS-guided intrahepatic PVE can be both technically feasible and safe in a live porcine model. Further animal studies are needed to demonstrate the efficacy and long-term safety of this challenging intervention.

Background and Objectives: Although endoscopic ultrasonography (EUS) features and criteria have been described in chronic pancreatitis, interoperator variability and ease of adoption limit their usefulness. The aim of the study is to define and validate EUS features of chronic pancreatitis in a multicenter, prospective Asian study. Methods: The study was conducted in two phases. In Phase I, expert endosonographers across Asia reviewed standardized EUS videos of the pancreas for internationally used diagnostic EUS features of chronic pancreatitis. Features that had good overall interobserver agreement were used to derive EUS features for the diagnosis of chronic pancreatitis. These features were then used in Phase II where they were validated in a prospective, multicenter case–control design. Results: For Phase I, thirty endosonographers rated 17 EUS imaging videos of the pancreas for 11 internationally used diagnostic EUS features of chronic pancreatitis. The top six EUS features that had good interobserver agreement (mean κ = 0.73) formed a set of criteria. These include hyperechoic foci with shadowing, lobularity with honeycombing, cysts, dilated ducts, dilated side branches, and calculi in the main pancreatic duct. For Phase II, 284 subjects (132 cases, 152 controls) were enrolled from 12 centers. All six features were useful with high accuracy ranging from 63.3% to 89.1%. Using the receiver operating curve, two or more of these six EUS features accurately define chronic pancreatitis (sensitivity 94.7% specificity 98.0%), with an area under the receiver operating characteristic curve of 0.986. Conclusion: This study thus defines and prospectively validates Asian criteria for chronic pancreatitis.

Background: Although endoscopic ultrasonography (EUS) is useful for diagnosis of pancreatic diseases, EUS findings are not employed in the clinical diagnostic criteria for autoimmune pancreatitis (AIP). Objectives: We assessed EUS findings in AIP and retrospectively analyzed them before and after steroid therapy. Methods: Twenty-one patients with AIP who received steroid therapy underwent EUS. Following seven EUS findings for AIP (a) hyperechoic foci, (b) strands, (c) lobularity, (d) reduced echogenicity, (e) capsule-like rim, (f) focal mass forming, and (g) contrast imaging pattern (poor vascular pattern) by contrast agent were assessed before and after steroid therapy. The total numbers of positive EUS findings before and after the steroid therapy were compared. Results: EUS findings before steroid therapy a, b, c, d, e, f, and g were observed in 100%, 91%, 86%, 91%, 86%, 52%, and 48%, respectively. EUS findings after steroid therapy a, b, c, d, e, f, and g were observed in 91%, 57%, 24%, 67%, 29%, 14%, and 10%, respectively. Strands, lobularity, capsule-like rim, focal mass forming, and contrast imaging pattern decreased significantly after steroid therapy (P < 0.05). The total number of positive EUS findings after the steroid therapy (5.1 ± 0.29) was significantly lower than their numbers before treatment (2.81 ± 0.13) (P < 0.001). Conclusion: Strands, lobularity, capsule-like rim, focal mass forming, and poor vascular pattern may reflect the disease activity of AIP. EUS is useful for the evaluation of response to steroid therapy.

Objectives: The aim of this study was to investigate the long-term outcomes after endoscopic ultrasonography (EUS)-guided pancreatic cyst ablation. Methods: In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts, clinically indeterminate cysts that required EUS fine-needle aspiration, and/or cysts that grew during the observation period. Treatment response was classified as complete resolution (CR), partial resolution (PR), or persistent cyst, with <5%, 5%–25%, and 25% of the original cyst volume, respectively. Results: The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis, there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8%) had adverse events (severe 1, moderate 4, and mild 11). Treatment response was as follows: CR, 114 (72.2%); PR, 31 (19.6%); and persistent cysts, 13 (8.2%). Twelve of 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50–85 months) of the 114 patients with CR, only two patients (1.7%) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR], 7.12; 95% confidence interval [CI], 2.72–18.67) and cyst size <35 mm (OR, 2.39; 95% CI, 1.11–5.16) predicted CR. Conclusion: Among patients with pancreatic cysts who achieved CR after EUS-guided cyst ablation, 98.3% remain in remission at 6-year follow-up. Unilocular and small cyst was predictive of CR.

Background and Objectives: Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) was reported as a useful tool for differential diagnosis of pancreatic tumor. However, the time to evaluate the intensity of enhancement is still uncertain. The aim of this study was to evaluate the vascularization patterns of solid pancreatic tumors. Methods: A total 46 patients who underwent CH-EUS for solid pancreatic tumors (pancreatic adenocarcinoma [PDAC] 33, pancreatic neuroendocrine tumor [PNET] 8, autoimmune pancreatitis [AIP] 5) were retrospectively analyzed. We examined maximum/minimum intensity (Max-I/Min-I), time to peak intensity (TTP), and time to start washout (TTW) of the lesions. Results: Max-I of CH-EUS showed isoenhancement pattern in 21 cases (64%) of PDAC and five cases (100%) of AIP. On the other hand, Max-I of NET showed hyperenhancement pattern in six cases (75%). Min-I of CH-EUS showed hypoenhancement pattern in 23 cases (70%) of PDAC, four cases (80%) of AIP, and five cases (63%) of NET. Median TTP of each solid pancreatic tumor was PDAC (22 s), AIP (20 s), and NET (17 s). Median TTW for PDAC was 38 s, AIP 45 s, and NET 33 s. Conclusions: TTP/TTW was different depending on each tumor. Further study is warranted to clarify the time intensity patterns.

Background and Objectives: The diagnosis of obstructive cholangiopathies by biliopancreatic endosonography has been extensively studied, and there is an extensive recognition of its role in the diagnosis of choledocholithiasis, biliopancreatic tumors, and extrinsic biliary compression syndromes. Cholangitis, a more frequent complication of biliary obstruction, which is responsible for much of its morbidity and mortality, has not been sufficiently linked to endosonographic findings. Methods: Our study attempted to define the diagnostic validity of endosonography in patients with acute cholangitis to limit the morbidity and mortality of the diagnostic delay and simultaneously achieve an etiological diagnosis and a primary management plan in patients at risk. A descriptive study was carried out to analyze the clinical histories of patients undergoing biliopancreatic endosonography for obstructive jaundice of any etiology and who were subsequently taken to endoscopic retrograde cholangiopancreatography (ERCP) to manage biliary obstruction, for which we compared the endosonographic findings compatible with acute cholangitis (thickening of the bile duct of 1.5 mm or more, presence of pericolangitic halo of at least 1.5 cm in length, and presence of mixed echogenicity content in the interior of the pathway biliar) with the presence of purulent drainage in ERCP. Results: A high frequency of these findings was found in patients with cholangitis, with biliary wall thickening being more common in 92.6% of cases. Moreover, to a lesser extent, the pericholangitic halo presence in 59.3% and ductal content in 66.7% of the cases. No differences were found in the demographic characteristics of patients such as age and sex. The etiology of biliary obstruction showed a behavior similar to that of historical controls. Conclusions: It is advisable to carry out studies with a greater statistical power, to validate our results, for a future inclusion of EUS in the diagnostic algorithm of clinical practice guidelines in acute cholangitis.

Background and Objectives: Most hepatic cysts are asymptomatic with no need for treatment. However, large symptomatic hepatic cysts need treatment. Ultrasound-guided or computed tomography-guided percutaneous aspiration alone is less invasive, but this approach is associated with high recurrence. A surgical approach for these cysts provides satisfactory long-term outcomes, but it is associated with high perioperative morbidity and complication. The aim of the present study was to evaluate the utility of endoscopic ultrasonography (EUS) guidance and percutaneous ethanol retention for the treatment of symptomatic large benign liver cysts. Methods: Patients were treated by ethanol retention therapy from April 2009 to December 2016 in Asan Medical Center. Ethanol retention therapy through percutaneous and/or EUS-guided approaches was performed. Primary outcomes are feasibility, efficacy, and safety of ethanol lavage. Results: Forty-one patients with 51 hepatic cysts were enrolled. Thirty-one cysts were drained by the percutaneous approach with a pigtail catheter, and 22 cysts were aspirated with EUS guidance. In three cases, both the percutaneous approach and EUS-guided puncture were used. During the median 13-month follow-up of the percutaneous approach group, the cysts showed 100% reduction. During the median 15-month follow-up of the EUS-guided group, the cysts showed nearly 100% reduction. This is a single-center retrospective study. Conclusion: Percutaneous catheter-guided and EUS-guided ethanol retention therapy showed good radiologic responses, low adverse events, and great efficacy in large hepatic cyst. Both of these methods could be used as primary treatment of large hepatic cysts.

Background and Objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous drainage when endoscopic retrograde cholangiopancreatography (ERCP) is not possible or has failed. This was a meta-analysis determining the success and safety of EUS-BD and comparing techniques. Methods: Full-text publications where more than 50 patients were reported were included. Primary outcomes were technical success, clinical success, and overall complications. Secondary outcomes were incidence of bile leaks, bleeding, cholangitis, perforation, pneumoperitoneum, and death. Results: Nine trials were included (576 patients). EUS-BD had a technical success of 89.45% (95% confidence interval [CI], 81.26, 97.63), clinical success 81.69% (95% CI, 65.30, 98.08), total complications 20.58% (95% CI, 10.26, 30.89), bile leaks 5.97% (95% CI, 2.23, 9.71), bleeding 4.8% (95% CI, 0.15, 9.45), cholangitis 3.18% (95% CI, 1.39, 4.96), perforation 1.56% (95% CI, 0.30, 2.82), pneumoperitoneum 3.53% (95% CI, 0.73, 6.33), and death 1.6% (95% CI, 0.00, 3.50). Comparing EUS-choledochoduodenostomy (EUS-CDS) to EUS-hepaticogastrostomy (EUS-HG), the latter had a higher rate of overall complications, odds ratio (OR) 2.04 (95% confidence interval [CI], 1.21, 3.44). There was no difference comparing EUS-CDS versus EUS rendezvous (EUS-RV), EUS-CDS versus EUS antegrade stenting, or EUS-HG versus EUS-RV. Hepatic access versus extrahepatic access had a higher complication, OR 1.49 (95% CI, 1.02, 2.07). Conclusions: A transhepatic approach and EUS-HG might have a higher overall complication rate, but data are limited.

Background and Objectives: Patients with hepatocellular carcinoma (HCC) or other malignancies with portal vein thrombosis (PVT) are at high risk for recurrent variceal bleeding. Recent evidence suggested that secondary prophylaxis (SP) for variceal bleeding may improve clinical outcomes. Methods: From 2014 to 2016, consecutive patients with HCC ± PVT or non-HCC malignancy + PVT with gastroesophageal variceal bleeding within 12 weeks were recruited for endoscopic ultrasound-guided cyanoacrylate injection (EUS-CYA) for SP. Varices = 3 mm on EUS were treated by EUS-CYA. Patients were followed up for 6 months after EUS or till death. A historical control group of HCC patients who underwent esophagogastroduodenoscopy-CYA (EGD-CYA) for index gastroesophageal variceal bleeding alone was identified in a prospective gastrointestinal bleed database from 2009 to 2013 for comparison. Results: Twenty-three patients underwent EUS-CYA for SP, while 33 HCC patients who underwent EGD-CYA for index variceal bleeding alone were identified as historical controls. In the EUS-CYA group, twenty patients had HCC + cirrhosis (85.0% also with PVT), while the other three patients had non-HCC malignancy + PVT. Majority of the HCC patients in both groups had Barcelona clinic liver cancer Stage C disease (85.0% vs. 75.8%, P = 0.421) and Child-Pugh Class B cirrhosis (55.0% vs. 71.4%, P = 0.241). Both the 30- and 90-day death adjusted cumulative incidence of rebleeding was significantly lower in the EUS-CYA group when compared to EGD-CYA control group (13% vs. 42% at 30-day, P = 0.023 and 22% vs. 61% at 90-day, P = 0.005, respectively). Conclusion: EUS-CYA for SP significantly reduces both the 30-day and 90-day death adjusted cumulative incidence of rebleeding in patients at high risk for recurrent gastroesophageal variceal bleeding when compared to EGD-CYA for index bleeding alone.

Background and Objectives: Although EUS-guided biliary drainage (EUS-BD) for malignant biliary obstruction (MBO) is increasingly reported, its long term outcomes are not fully discussed. Methods: Consecutive patients undergoing EUS-BD for unresectable MBO were retrospectively studied. Data on recurrent biliary obstruction (RBO) including re-intervention and other stent-related complications were extracted. Results: Between Aug 2011 and Dec 2016, EUS-BD was performed in 96 patients (82 EUS-HGS and 14 EUS-CDS, 95 covered metal stent [CMS] and 1 plastic stent) at 4 tertiary referral centers. Biliary drainage prior to EUS-BD had been performed in 54%. The major causes of MBO were pancreatic cancer (52%) and biliary tract cancer (28%). Duodenal invasion (64%) and surgically altered anatomy (25%) were two major reasons for EUS-BD. Technical success rate was 98% with two technical failures (1 stent misplacement and 1 failed insertion of CMS delivery). The incidence of RBO was 36% and a median cumulative time to RBO was 6.8 months. The causes of RBO were non-tumor related (hyperplasia 17%, migration 9%, sludge 5%, reflux 2% and kink 2%), other than de novo stricture (2%). Re-intervention was successfully performed via EUS-BD route in 89% (22 stent-in-stent, 5 balloon sweep, 3 stent exchange and 1 additional antegrade stenting). Other re-interventions were 2 conversion to transpapillary stenting, 1 conversion from CDS to HGS and 1 PTBD. The incidence of other complications was 29%. Conclusions: The incidence of RBO necessitating re-interventions was not rare in EUS-BD for MBO but re-intervention via EUS-BD route was technically feasible in most cases.

Background and Objectives: Lumen-apposing large diameter fully covered self-expandable metallic stents (LAFCSEMS) customized for the drainage of pancreatic fluid collections are now available. LAFCSEMS allow more effective drainage as compared to plastic stents (PSs), and an endoscope can be easily inserted for direct endoscopic debridement and direct endoscopic necrosectomy (DEN). The large diameter may allow solid debris to pass out spontaneously. This study examined whether LAFCSEMS can reduce the need for DEN. Methods: Data of patients who underwent endoscopic ultrasound-guided drainage of symptomatic walled-off collections from November 2006 to January 2017 were reviewed. Primary outcome measures were the need for and frequency of DEN. Results: Forty-two patients underwent 44 procedures. The indications were infected pseudocysts (4), pseudocysts with mass effect (18), infected walled-off necrosis (19), and intra-abdominal abscess (93). PS was used in 32 and LAFCSEMS in 14 (two had PS changed to LAFCSEMS to improve drainage). Technical and clinical success rates were 100% and 95.5%, respectively. When LAFCSEMS were compared with PS, there was no difference in the need for DEN (41.7% vs. 37.5%, P = 0.8) and the median number of DEN sessions (P = 0.554). Conclusions: LAFCSEMS facilitate but do not obviate the need for endoscopic debridement in infected collections.

Background and Objectives: Lumen-apposing metal stents (LAMSs) have shown promise for management of walled-off necrosis (WON). The impact of ductal leaks and disconnection on long-term results is unclear. We aimed to determine whether ductal leaks and disconnection influence WON recurrence after short-term drainage with LAMS. Methods: Patients with WON underwent LAMS placement. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were done on day 8. A 5F stent was placed in patients with ductal leak. LAMS was removed when the cavity collapsed completely. Patients were followed up at 3-month intervals Results: Eighty-eight patients with WON underwent LAMS placement. Sixty-four patients (72.72%) underwent necrosectomy (median session 3). Overall, 15 (17%) patients had complications (12 fever, 3 bleed). All LAMSs were removed at a median of 3.5 weeks (2–17 weeks). ERCP showed ductal disconnection and leak in 53 (60.2%) and 61 (69.3%) patients, respectively. A 5F stent was placed in 56/61 (91.8%) patients with ductal leak. There were 8 (9.09%) recurrences at a median follow-up of 22 months. Recurrence in patients with disconnection was higher than in those without (13.2% vs. 2.8%, P = 0.08). There were 4 (7.1%) recurrences in patients who underwent pancreatic duct stenting and 4 (12.1%) in those who did not (P = 0.45). Seven recurrences partially regressed on follow-up and did not require therapy. Conclusions: Short-term LAMS placement is an effective therapy for WON. There is a high prevalence of ductal leaks and disconnection in patients with WON. Recurrences are more common in patients with disconnection and are not impacted by ductal stent, and majority do not require therapy.

Background and Objectives: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is a commonly used tool in the diagnosis of mediastinal lymphadenopathy. However, less is known of the value of ProCore fine needle biopsy (FNB). This prospective, comparative study compares the outcomes of EUS-guided FNA (EUS FNA) and FNB, in patients with mediastinal lymphadenopathy and masses of unknown origin. Methods: Results were compared for cellularity and adequacy for all patients who had cytological/histological specimens taken. Patients were randomized into Group A (undergone EUS FNA only) and Group B (EUS FNA + FNB). Patients were followed up for 3 months and final diagnosis was made. Results: Sixty-one patients underwent EUS for mediastinal lymphadenopathy and had specimens taken through FNA, FNB, or both. Four patients lost to follow-up and therefore were excluded from analysis. Of the remaining 57 patients, adequacy and inadequacy of EUS FNA sample were seen in 41 (71.93%) and 16 (21.07%), respectively. Of the 29 patients undergoing both procedures, the adequacy in FNA and FNB were 20 (68.97%) and 23 (79.31%), respectively. The difference was not statistically significant (P > 0.05). Conclusions: The diagnostic sensitivity of aspirated material obtained using EUS-FNA needle and ProCore needle in mediastinal masses and lymph nodes was comparable in our study.

Background and Objectives: Duplication cyst of gastrointestinal tract is uncommon, especially stomach. Most cases were identified incidentally while receiving endoscopy for other unrelated signs and symptoms. Most gastrointestinal duplication cysts are asymptomatic, and sometimes, hemorrhage could be presented if the overlying mucosa is eroded. Here, we presented a case of gastric duplication cyst presented as a subepithelial tumor on esophagogastroduodenoscopy (EGD) and we performed endosonography (EUS) for diagnosis and modified endoscopic mucosal resection (EMR) for treatment in one session of endoscopy. Case Report: A 43-year-old female presented to our outpatient department for a second opinion about the management of a gastric subepithelial tumor. She received an EGD for health examination and a gastric subepithelial tumor over antrum was identified incidentally. EUS was scheduled and it demonstrated an anechoic homogeneous lesion arising between muscularis mucosae layer (second layer) and submucosa layer (third layer) on the anterior wall of the antrum (size: 8.3 mm × 4.7 mm). Duplication cyst of the stomach was impressed, and we removed it with modified EMR subsequently in one session of endoscopy. Histology disclosed two cystic lesions lined by single layer of gastric type mucosal epithelium and walled by well-developed smooth muscle layers, consistent with duplication cyst and gastric duplication cyst, was diagnosed. Conclusion: Gastric duplication cyst could be diagnosed with EUS, and modified EMR is an option for management.

Background and Objectives: Fistula-in-ano remains a diagnostic and treatment challenge. Accurate preoperative assessment of the nature of fistula is vital for surgery. Endoanal ultrasonography (EAUS) plays a major role in fistula assessment. EAUS can be performed using two-dimensional and three-dimensional (3D) views. The study objectives were to compare 3D EAUS with surgical findings and to determine the role of 3D view in fistula assessment. Methods: A retrospective analysis was performed using a database maintained prospectively by a tertiary care unit in Sri Lanka since 2007. Twenty-eight were analyzed. The association was determined using Cohen’s Kappa test. Results: Male/female ratio was 25:3. Mean age was 36.75 years. On 3D EAUS, primary tract was transphincteric and intersphincteric in 17 (60.7%) and 1 (3.6%), respectively. Abscesses were detected in 11 (39.3%). At surgery, transphincteric and interspincteric tracts were found in 22 (78.6%) and 5 (17.9%), respectively. Abscesses were detected in 6 (21.4%). 3D views showed poor association (κ = 0.164) with surgical findings. Poor association (κ = 0.105) exists between abscess detection by 3D EAUS and surgery. Conclusion: 3D EAUS has poor association with surgical findings in preoperative fistula assessment and abscess detection.

Methods: All patients for lymph node assessment were subjected to endoscopic ultrasound-guided fine needle aspiration (EUS FNA) and core biopsy. First pass made with a stylet and the subsequent passes without the stylet. First two passes were made with a 22-gauge needle, material taken for cytology. Third and the fourth pass were made with 19-gauge needle and material taken for core biopsy in formalin. Fifth pass was made with 19-gauge needle and material taken in saline for GeneXpert and SOS acid-fast bacilli (AFB). Results: Total number of patients was 72. The most common sites were mediastinum - 26, peripancreatic nodes - 39, celiac - 05, and nodes at porta - 2. Positive Diagnosis: 70 (97.2%) Inconclusive: 2 (2.8%) Diagnostic Trends: Tuberculosis: 42 (58.3%) Metastatic Carcinoma: 18 (25%) Lymphoma: 6 (5.6%) Inflammatory: 2 (2.8%) Core Biopsy: Total: 72 Granuloma with Caseation seen: 25 (59.5%) Gene Xpert positive: 17 (40.5%) immunohistochemistry (IHC) Possible in Lymphoma Cases: 4 (66.7%) Need for repeat core biopsy: 2 (33.3%) Blood contamination: 60 (83.3%). Conclusion: EUS FNA and fine needle biopsy are effective modalities for the assessment of mediastinal and abdominal nodes, with a high accuracy of 97.2%. Adequate core biopsy is obtained for GeneXpert, AFB culture in up to 90% cases. In cases of lymphoma, the core obtained gave positive IHC grading in 66.7% cases, suggesting a need for a better core biopsy needle. Blood contamination remains a problem for the pathologist in core taken with a 19-gauge needle.

Background: The first report on the performance of a recently introduced flexible 20-gauge ProCore biopsy needle was promising, with a diagnostic yield of >85%. However, before implementation of this device, its reproducibility should be established not only in the hands of academic experts but also in nonacademic practice. Objectives: To evaluate the interobserver agreement among expert and nonacademic pathologists in grading the quality and diagnostic value of specimens obtained with the new flexible 20-gauge ProCore fine needle biopsy (FNB) needle (Cook Medical, Limerick, Ireland). Methods: Five international endoscopic ultrasound centers prospectively collected 74 samples (39 solid pancreatic masses and 35 lymph nodes) using a new needle. All samples were independently reviewed by five expert academic and five nonacademic pathologists for sufficiency of tissue quality, percentage of target cells present, presence of tissue cores, suitability for additional analysis (i.e., immunohistochemistry), and diagnostic classification (nondiagnostic, benign, neoplastic, or malignant). Agreement was calculated using the Fleiss’ kappa statistic and 95% confidence intervals (CIs). Results: Overall, 91% of cases were considered to be of sufficient quality, with moderate agreement among the ten reviewing pathologists [κ = 0.49, [Table 1]]. Agreement was higher within the group of expert academic pathologists (P = 0.02). Interobserver agreement on the diagnostic classification was good among both academic (κ = 0.62; 95% CI 0.57–0.67) and nonacademic pathologists (κ = 0.59; 95% CI 0.55–0.64). Regarding sample quantity, tissue cores were considered present in 70% of cases (κ = 0.37), with a higher level of agreement among expert pathologists (P < 0.001). As for cellularity of the sample, the presence of ≥50% of target cells was reported in 68% of cases (κ = 0.31). In addition, suitability for additional analyses was rated as positive in the majority of samples (76%), with higher agreement among expert academic pathologists (P < 0.001). When comparing pancreatic to lymph node samples, agreement on the diagnostic classification was higher for lymph nodes (κ = 0.64; 95% CI 0.61–0.67) than for pancreatic masses (κ = 0.54; 95% CI 0.51–0.58, P < 0.001). In addition, lymph node specimens provided higher agreement with regard to possibility for additional analysis (κ = 0.51; 95% CI 0.46–0.56 vs. κ = 0.38; 95% CI 0.33–0.43, P < 0.001). Agreement on specimen quality was higher for pancreatic samples (κ = 0.62; 95% CI 0.57–0.67 vs. κ = 0.43; 95% CI 0.38–0.48, P < 0.001). Conclusion: There was good interobserver agreement among both expert academic and nonacademic pathologists in the assessment of the quality and diagnostic value of specimens obtained with the new 20-gauge ProCore biopsy needle. Follow-up data are required to confirm the diagnostic accuracy of this agreement.

Background and Objectives: Endoscopic ultrasound (EUS) fine needle biopsy (FNB) needles were designed to improve histologic yield, while maintaining the flexibility to permit ease of use. However, the diagnostic benefit of EUS-FNB needles as compared to the conventional fine needle aspiration (FNA) needles remains unclear. This study aimed to identify the diagnostic accuracy of combined needle use of a new 20-gauge ProCore FNB needle and a 25-gauge FNA needle. Methods: For this study, cases were selected in which both the 20-gauge ProCore FNB needle and the 25-gauge FNA needle were used during a single EUS procedure for sampling of a solid pancreatic mass, lymph node, or submucosal mass. Tissue acquisition was performed in the course of the ASPRO trial, a multicenter randomized study comparing the diagnostic value of 20-gauge ProCore FNB and 25-gauge FNA needles (ClinicalTrials.gov: NCT02167074). The protocol allowed additional sampling with the nonassigned needle, at the discretion of an endosonographer. Results: Of all 615 patients who were randomized for the ASPRO study, 74 were sampled with both needle types. In these combined needle cases, FNA was used first in 24 and ProCore FNB in 50 cases. Target lesions encompassed 39 solid pancreatic lesions, 18 submucosal masses, and 17 lymph nodes. Most pancreatic lesions were located in the head (25/39), lymph nodes were mainly located in the abdomen (15/18), and submucosal lesions were located in the stomach (8/20), esophagus (4/20), small intestines (3/20), and rectum (3/20). The main reason to use ProCore in addition to FNA was to collect more tissue for ancillary testing (79%). FNA was generally used in addition to ProCore to allow for on-site pathological assessment (76%). The regimen of FNA followed by ProCore resulted in 100% accuracy, while for ProCore followed by FNA, 88% was reached (P = 0.086). The type of target lesion, either pancreatic or nonpancreatic, did not affect the diagnostic accuracy of the two sampling regimens (odds ratio 1.2, 95% confidence interval 0.22–6.61, P = 0.834). Conclusion: FNA followed by ProCore FNB provides for a 100% diagnostic accuracy and tends to outperform ProCore FNB followed by FNA. Accuracy rates were independent of the type of target lesion.

Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) allows obtaining adequate material for cytological diagnosis of upper gastrointestinal (GI) lesions that is safe with complication rate ~2%. It is more advantageous over other imaging techniques since it provides real-time imaging and reduction of complications due to the needle proximity to the lesion. Worldwide, data support EUS-FNA in providing cytological diagnosis (80%–95%) with sensitivity and specificity of 90% and 100%, respectively. Methods: This retrospective cross-sectional study included adults who underwent upper GI EUS-FNA from January 2010 to December 2015 at St Luke’s Medical Center, Global City. Blood dyscrasia and history of steroid-, nonsteroidal anti-inflammatory drug- or any anticoagulant-intake were excluded. Medical records were obtained from our databank. Demographics, indications with corresponding success rates, EUS-FNA technique, and complications were reviewed. Frequency, central tendency, variability, and effect measures were used. Results: From the 423 upper GI EUS, 68 patients underwent EUS-FNA (7:1 female:male ratio, mean age 62.1 ± 14.9 years). Mean size (mm) of the lesions observed was 33.3 ± 16.4 (range 4–90). Most frequent location was pancreas (63%), with 81% observed solid lesions (63% adenocarcinoma). Average number of passes is 3 (range 1–6). Indications were cyst aspiration and biopsy of submucosal mass, lymph node, deeper luminal lesions, and solid pancreatic lesions. Success rate ranges 97%–100%. Complication rate was 1.3% as mild pancreatitis. No hemorrhage, perforation, infection, or tumor-seeding was observed. Conclusion: EUS-FNA is a safe and effective diagnostic modality in obtaining definitive histologic diagnosis of upper GI lesions with 97–100% success rate. Complication rate is 1.3%.

The gold standard for diagnosis of peritoneal tuberculosis is growth of Mycobacterium tuberculosis on ascitic fluid or peritoneal culture. Due to the nonspecific signs and symptoms of disease, its early diagnosis is difficult, especially in patients with decompensated cirrhosis. The reported sensitivity of ascitic fluid is low, and to obtain tissue for peritoneal biopsy in patients with cirrhosis is difficult. Thus, there is an urgent need to explore newer diagnostic modalities, especially those that can provide perioneal tissue by less invasive means. Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is a good alternative to obtain peritoneal tissue for establishing the diagnosis of peritoneal tuberculosis (TB). We hereby report the use of EUS- FNA of the peritoneum in five patients with decompensated cirrhosis, in whom the diagnosis could not be confirmed by other means; thus, we propose EUS-FNA of the peritoneum as a new, safe, and unexplored technique for diagnosis of peritoneal TB.

Background and Objectives: Thoracocentesis is the first diagnostic procedure for pleural effusion (PE). If diagnosis after thoracocentesis remains uncertain pleural biopsy, either computed tomography/ultrasonography (CT/USG) guided or thoracoscopy is required for definitive diagnosis. We present the data about evaluation of undiagnosed PE by endoscopic ultrasound (EUS)-guided pleural aspiration or fine needle aspiration cytology (FNAC) of the lymph nodes/pleural deposits. This is the first case series regarding EUS-guided FNAC of the pleural deposits or nodules. Methods: Eleven patients of undiagnosed PE were evaluated by EUS. The CT/USG reports were reviewed before EUS. The PE aspiration was performed by EUS needle. The EUS-FNA of the mediastinal nodes or pleural deposits was done by a 22-gauge needle. Results: Seven patients had right-sided and four had left-sided PE. Three cases had unsuccessful attempts/complications at US-guided aspiration. A single pass was successful in diagnostic aspiration and the aspirated fluid was suggestive of tuberculosis (TB). The remaining eight cases had nondiagnostic aspiration, and FNAC with rapid on-site evaluation was done from mediastinal lymphadenopathy or pleural deposits. Four cases with mediastinal lymphadenopathy had granulomatous lesions. Four cases with pleural deposits had malignancy. Conclusions: EUS-guided imaging introduces a totally different path/technique of imaging for inspection of the pleural space. EUS-FNA can be performed as a safe procedure in undiagnosed PE. At present, it appears that EUS-guided evaluation is an alternative modality for evaluation of undiagnosed PE, in the cases who are unfit for thoracoscopy and as an alternative or adjunct to USG/CT-guided aspiration or biopsy. Further studies will be required to clarify its exact role in pleural diseases.

Background: Obtaining a tissue diagnosis from a lung tumor or a mediastinal lymph node located lateral to aorta (para-aortal) is a diagnostic challenge. Invasive surgical procedures such as mediastinotomy, thoracotomy, or video-assisted thoracic surgery are required for the diagnosis of these lesions. Lymph nodes on the “far side” of major blood vessels can be visualized by endoscopic ultrasound (EUS); however, fine needle aspiration (FNA) is avoided due to concern for bleeding complications. Objectives: To evaluate the feasibility, yield, and safety of EUS-guided transaortic FNA of lung tumors and para-aortic lymph nodes. Methods: A retrospective case series of 12 consecutive patients with suspected lung cancer or tuberculosis who underwent transaortic fine needle aspiration cytology during a study period of 7 years. In all cases, the para-aortal lesion was the only site suspicious for malignancy/tuberculosis (other lesion/lymph node if present were negative). Seven patients had left-sided lung mass (mean size 30 mm). Four patients had enlarged para-aortic lymph node (mean size 18 mm, range 8–22 mm). All aspirates were obtained under real-time US-guided FNA using a 22/25-gauge needle. A single real-time FNA of the lung mass or lymph node was performed. Results: The final diagnosis was known in 11 patients (seven lung carcinoma, three tuberculosis, and one thymolipoma). EUS-FNA established diagnosis in 9 of 12 patients (75%). One aspirate revealed reactive nodal tissue, and one demonstrated nonrepresentative material. One procedure was abandoned due to complication. Conclusions: This case series demonstrates the feasibility and probable safety of single EUS-guided transaortic aspiration in para-aortic lesions. The diagnostic yield is 75%.

Background and Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a procedure of choice for diagnostic evaluation of endoluminal and periluminal lesions. Tissue sample can be obtained by EUS-FNA cytology or cellblock (CB). The aim of the present study is to compare diagnostic yield of EUS-FNA CB and/or cytology in the absence of on-site pathologist following a protocol-based EUS-FNA approach in solid lesions. Methods: Subjects who underwent EUS FNA at our center were included in this 2-year retrospective study. The etiological, clinical, and investigation details were recorded on uniform structured data forms. Superiority of the yield was calculated by McNemar’s test for P value. Results: Pancreatic masses were the most common indications (34%), followed by nodes (29%) in 114 EUS-FNA solid lesions. The diagnostic yield for EUS-FNA cytology was 68%, CB was 77%, and combined was 81%. There was no statistical significance in the yield between cytology and CB. CB was superior in pancreatic neuroendocrine tumor, lymphoma, stromal tumors, and liver mass evaluations. Conclusions: EUS-FNA needles provide good specimen for CB, and combination of CB with cytology increases the yield. CB is preferred over cytology in selected patients.

Background and Objectives: Role of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in patients with lymphadenopathy in terms of diagnostic adequacy and safety in large population is not well defined. The aim of the current study was to evaluate diagnostic adequacy and safety of EUS FNA in patients with lymphadenopathy. Methods: This was a retrospective study from October 2010 to September 2015 at tertiary care center in Delhi-National Capital Region. We analyzed data of 1005 EUS-guided FNA of the lymph node. Results: The study cohort comprised 1005 lymph nodes in 865 patients; 68% were males, mean age was 50 ± 14 years. Indication of FNA was to look for etiology of pyrexia of unknown origin, staging of malignancy, or unexplained weight loss. FNA was taken from mediastinal nodes (n = 528, 52.5%) and abdominal nodes (n = 477, 47.5%). Median size of nodes at long axis and short axis was 17 (12–25.7) and 10 (8–15) mm, respectively. Adequate material by FNA was obtained in 92.8% cases. The cytopathologic diagnoses were malignancy in 153 (15.2%), granulomatous change in 452 (42%), and reactive lymphadenopathy in 328 (35.6%). Lymph node with a size >1 cm at short axis (n = 444) was more pathological (70.6%) than size <1 cm (n = 133, pathological in 43.1%), P = 0.00. There was no statistically difference between the groups regarding type of needle, number of passes, and cellularity. Procedure-related adverse effects were encountered in six patients (0.8%). Four patients had mild mucosal bleeding in chronic liver disease patients and two had mild hepatic encephalopathy related to sedation. Conclusion: EUS FNA of the lymph nodes has good diagnostic adequacy and safety.

Background and Objectives: It is difficult to get tissue diagnosis from the adrenal glands by radiological imaging, particularly from left adrenal due to their anatomic location. Endoscopic ultrasound-guided offers less invasive mode of fine needle aspiration (FNA) due to proximity to adrenals. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal lesions. Methods: It was a retrospective study conducted from October 2010 to September 2016 at a single tertiary care center in Delhi-National Capital Region. We analyzed data of eighty patients with adrenal lesions, in whom EUS FNA was performed. Results: Of the eighty patients, mean age was 56 ± 12.2 years; there were 63 males. Indications of FNA were pyrexia of unknown origin (n = 52), evaluation for metastasis (n = 18), and incidentally detected adrenal enlargement (n = 10). FNA were taken from left adrenal in seventy patients by transgastric route, while in ten patients, FNA was taken from right adrenal using transduodenal route. Technical successes and diagnostic adequacy of specimen were achieved in 100% cases. A 19-gauge needle was used in majority (80%). Median number of passes was 3. The cytopathological diagnoses were tuberculosis (n = 36), histoplasmosis (n = 13), metastatic lung carcinoma (n = 10), adrenal adenoma (n = 9), hepatocellular carcinoma (n = 4), carcinoma gall bladder (n = 2), lymphoma (n = 2), endometrioid carcinoma (n = 1), neuroendocrine tumor (n = 1), adrenal lipoma (n = 1), and adrenal myelolipoma (n = 1). No procedure-related adverse events were reported. Conclusions: EUS-FNA is a safe and effective method for evaluating adrenal lesions.

Background and Objectives: Fine needle aspiration (FNA) of the enlarged lymph nodes or adrenal is advisable in patients with cirrhosis who have hepatocellular carcinoma (HCC) or pyrexia of unknown origin (PUO), before choosing optimal management strategy. It is difficult to perform percutaneous FNA due to the presence of collaterals and difficult anatomic location. The influence of endoscopic ultrasound (EUS)-guided FNA in patients with cirrhosis has been seldom reported. Patients and Methods: Patients with HCC (n = 97, no extrahepatic disease on positron emission tomography-computed tomography), and PUO (n = 20) or >1 cm lymph nodes on imaging during liver transplantation workup (n = 3) underwent EUS-guided FNA. The data are represented as mean (standard deviation) or median (interquartile range). Results: One hundred and twenty (100 males) patients, with the mean age 56 ± 8 years, had EUS-guided FNA from 129 sites (95 abdominal nodes, 32 mediastinal nodes, and 2 left adrenals). The platelet counts were 1.4 (1–1.7) ×10⁵/cumm and international normalized ratio was 1.2 (1.07–1.43); lymph nodes measured 1.5 (1–1.8) cm and 0.9 (0.7–1.3) cm at long and short axis, respectively. The Child’s score and Model for End-Stage Liver Disease scores were 7 (6–9) and 11 (8–15), respectively. The cytopathological diagnoses were metastatic disease in 28 (21.7%; two mediastinal nodes, one left adrenal, rest abdominal nodes), granulomatous change in 14 (10.9%), histoplasmosis in 2 (1.6% including one left adrenal), and reactive lymphadenopathy in 73 (56.6%) specimens. Twelve (9.3%) specimens were inadequate for opinion. Two patients had transient sedation-related encephalopathy (both Child’s C), and one had mild ooze from the FNA site that ceased spontaneously. Conclusion: EUS-guided FNA of the lymph nodes/adrenal is safe and significantly impacts management in patients with cirrhosis.

Objectives: To analyze our data of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) done over the last 3 years. Methods: All cases referred for EUS-guided FNA were studied retrospectively. FNA was performed with a 22-gauge needle in the mediastinum and stomach. A 25-gauge was used for FNA from the duodenum. Core biopsy was taken from mediastinum and stomach with a 19-gauge needle and duodenum with a 22-gauge needle. All cystic lesions were aspirated with the 19-gauge needle. The first pass was made with a stylet and the subsequent passes were made without a stylet. Results: Total number cases – 344, pancreatic space-occupying lesion (SOL) – 142, pancreatic cystic lesions – 22, lymph nodes – 77, common bile duct (CBD) and ampullary masses – 42, gall bladder masses – 7, mediatinal masses – 9, liver SOL – 7, others – 39, Others: Antral mass – 3, gastric wall thickening – 6, porta masses – 5, para-aortic masses – 5, submucosal gastric mass – 15, posterior rectal mass – 2, retroperitoneal masses – 3. Findings: (1) In West India, pancreatic tumors and lymphadenopathies are the most common indications. (2) Core biopsy is a short coming for cases which require immunohistochemistry, for example, neuroendocrine tumor, lymphoma, and mediastinal tumors. (3) EUS is the most important tool for pancreatic cystic lesions. (4) EUS is an important tool for diagnosis of CBD and gallbladder masses. EUS gives accurate diagnosis in gastric submucosal lesions, infiltrative gastric wall lesions, and retroperitoneal masses. Conclusions: EUS has changed the paradigm in management of difficult to treat diseases such as pancreatic masses, cystic lesions of the pancreas, and lymphadenopathy in Western India.

Background and Objectives: Endosonography-guided fine needle aspiration biopsy (EUS-FNA) with rapid on-site evaluation (ROSE) by cytopathologists improves the diagnostic capacity of the EUS. We investigated the utility in the ROSE we carried out by endoscopists with training in cytopathology, to evaluate if the samples were adequate or not adequate. Methods: Between March and October 2015, 49 patients with solid or cystic lesions of the gastrointestinal tract were taken to EUS-FNA and eight patients were taken to biliary brushing. Two endoscopists with short training in cytopathology performed the ROSE, categorizing the samples obtained as adequate or not adequate, and the results were compared with the evaluation of a pathologist following the same criteria to evaluate the concordance. Results: EUS-FNA 1 (measure of kappa agreement 81%) and puncture number 2 EUS-FNA 2 (measure of kappa agreement 78%). Conclusion: Endoscopists may acquire basic cytopathology skills to perform ROSE and the findings are consistent with those of a pathologist. The ROSE is easy and fast and its implementation does not require a complete infrastructure.

Background and Objectives: Fistula-in-ano remains a diagnostic and treatment challenge. Accurate preoperative assessment of nature of fistula is vital for surgery. Endoanal ultrasonography (EAUS) plays a major role in fistula assessment. EAUS can be performed using two-dimensional (2D) and three-dimensional views. The study objectives were to compare 2D EAUS with surgical findings and to determine the role of 2D view in fistula assessment. Methods: A retrospective analysis was performed using a database maintained prospectively by a tertiary care unit in Sri Lanka since 2007. A total of 101 were analyzed. The association was determined using Cohen’s Kappa test. Results: Male/female ratio was 92:9. Mean age was 39.56 years. On 2D EAUS, primary tract was transsphincteric and intersphincteric in 74 (73.3%) and 16 (15.8%), respectively. Abscesses were detected in 22 (21.8%). At surgery, transsphincteric and intersphincteric tracts were found in 69 (68.3%) and 21 (20.8%), respectively. Abscesses were detected in 18 (17.8%). 2D views showed fair association (κ= 0.298) with surgical findings. Moderate association (κ= 0.440) exists between abscess detection by 2D EAUS and surgery. Conclusion: 2D EAUS has fair association with surgical findings in preoperative fistula assessment and moderate association in abscess detection.

Background and Objectives: The role of endoscopic ultrasound-guided fine needle aspiration (EUS FNA) for mediastinal lesions has long been recognized, but case reports on pericardial aspiration ± biopsy and biopsy of intra-cardiac lesions are also increasingly being described. A 58-year-old female with a history of left breast carcinoma underwent a mastectomy with chemoradiotherapy in 2008. She had a tumor recurrence in 2014 with malignant pleural and pericardial effusions. A transthoracic pericardiocentesis (TTP) was done once in November 2015 for symptomatic pericardial effusion. In March 2016, she presented with progressive dyspnea. A transthoracic echocardiograph showed a posteriorly located pericardial effusion (29 mm) with diastolic collapse of the right atrium. She was unsuitable for both TTP (due to poor window) and pericardial fenestration (in view of the history of pleurodesis, previous thoracic instrumentation, and poor prognosis). Therefore, a transesophageal drainage with EUS scope was performed. Methods and Results: The pericardial sac was punctured with a 19-gauge needle (EchoTip^®, Cook Medical) and 245 ml of hemorrhagic fluid was aspirated. There were no immediate or late complications. The patient experienced symptomatic improvement, significant reduction in the size of the pericardial effusion, and absence of diastolic right atrial collapse. She remained asymptomatic with no recurrence of effusion. She died 5 months later from pneumonia. Conclusions: EUS-guided pericardiocentesis may be an alternative for TTP in selected cases.

Background and Objectives: A wide variety of imaging strategies are used to provide comprehensive preprocedural information about hepatic angioarchitecture. Currently, multidetector computed tomographic angiography and magnetic resonance angiography are complementary modalities of hepatic angioarchitecture evaluation before liver surgeries. An adequate maintenance of segmental hepatic venous drainage is also important as there is no adequate venovenous shunt between hepatic venous systems. Linear endoscopic ultrasound (EUS) can offer a detailed evaluation of hepatic veins, help in the assessment of liver segments, and can offer a possible route for EUS-guided vascular endotherapy involving hepatic veins. Methods: This article describes applied anatomy of liver lobes, sectors, and hepatic veins with techniques of imaging of hepatic veins and hepatic vein branches from four stations: abdominal part of esophagus, fundus of stomach, duodenal bulb, and descending duodenum. The imaging of hepatic veins is usually aided by proper identification of the inferior vena cava and the gallbladder. EUS of hepatic veins can help in identification of individual sectors and segments of liver. EUS offers additional superiority in assessing the flow dynamics of individual hepatic veins and also provides assessment of the anatomical features of hepatic vein length, diameter, pattern of joining, and evaluation of segmental venous drainage. Conclusions: This article describes a standard technique for visualization of hepatic veins. Knowledge of the hepatic venous territories and “venous drainage map” may provide useful information for complex liver surgeries and therapeutic procedure involving hepatic veins.

Background and Objectives: It is difficult to evaluate patients with suspected pancreatic neoplasm based on imaging studies such as computed tomographic (CT) scan/magnetic resonance image (MRI), especially in getting a tissue diagnosis and differentiating from benign conditions such as autoimmune pancreatitis, tuberculosis. The objective of the study was to evaluate the different etiologies and the accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis of pancreatic mass. Methods: This was a retrospective analysis and included patients who underwent EUS-FNA at a tertiary care hospital in the past 6 months for pancreatic masses or space-occupying lesion noted on imaging modalities such as CT/MRI. The main outcome measurements were (1) prevalence of pancreatic adenocarcinoma, (2) diagnosis of other benign etiologies, and (3) performance characteristics of EUS-FNA for identifying malignancy. Results: A total of 46 patients were included in the analysis; a pancreatic lesion/mass was identified on EUS in 44 patients. The final diagnosis includes adenocarcinoma (n = 28), neuroendocrine tumor (n = 4), gastric gastrointestinal stromal tumor infiltrating pancreas (n = 1), necrotic abscess (n = 2), pancreatic tuberculosis (n = 2), inflammatory head mass (n = 4), and autoimmune pancreatitis (n = 3). Those patients without any pancreatic mass were two (chronic pancreatitis [n = 1], and normal pancreas [n = 1]). EUS-FNA had an accuracy of 96% for diagnosing malignant neoplasm, with 95% sensitivity and 99.0% specificity. Conclusions: EUS-FNA is a highly accurate and accepted diagnostic modality for diagnosis of pancreatic mass.

Background and Objectives: Carcinoma of unknown primary (CUP) origin accounts for 3%–5% of cancer cases. Endoscopic ultrasound (EUS) is an excellent modality to evaluate the pancreaticobiliary tract. However, its role in evaluation of patients with CUPs has never been studied. This pilot study is a retrospective study of prospectively collected data to evaluate whether EUS is effective in diagnosing hitherto unidentified pancreaticobiliary primary in patients with CUPs. Patients and Methods: Ten patients with CUPs with suspected pancreaticobiliary origin were referred to us for the evaluation of pancreaticobiliary tract using EUS. All the patients had normal pancreas and biliary system on previous imaging including positron emission tomography/computed tomography. Patients underwent EUS using a linear echoendoscope. Results: Two of the ten patients (20%) were found to have lesions on EUS, both in the gallbladder and in the neck region. The lesions measured 6 and 8 mm in diameter. Both the lesions were sampled successfully, and adenocarcinoma was detected. None of the lesions had mucinous morphology. There were no periprocedural complications. Conclusion: EUS is an effective modality to detect occult primary in patients with CUPS with suspected pancreaticobiliary origin. Larger studies assessing its cost-effectiveness and identifying positive predictive factors are needed before incorporating EUS in the routine diagnostic workup of these patients.

Background and Objectives: Contrast-enhanced endoscopic ultrasonography (CE-EUS) is noninvasive and can evaluate pancreatic tumors in detail. We investigated the usefulness of CE-EUS for diagnosis of pancreatic tumors. Methods: CE-EUS was performed for consecutive patients having a pancreatic solid lesion, and tumors were classified into three vascular patterns (hypervascular, isovascular, and hypovascular) at two time phases (early phase and late phase). Correlation between vascular patterns and histopathology of pancreatic tumors was ascertained. Results: The final diagnoses of 235 tumors histopathologically examined by surgery, EUS-guided fine needle aspiration (EUS-FNA), or biopsy of liver metastases were pancreatic cancer (PC) (n = 179), inflammatory mass (n = 12), autoimmune pancreatitis (n = 11), neuroendocrine tumor (n = 15), and others (n = 18). In late-phase images, 162 of 179 PCs had hypovascular pattern, for a diagnostic sensitivity, specificity, and accuracy of 91%, 68%, and 85%, respectively. In PCs, cases in which the contrast effect changed from early phase to late phase were seen in 80.7%, and this rate was significantly higher than others (P = 0.007). Hypervascular pattern was seen in five cases, and all of them were neuroendocrine tumor. Conclusion: CE-EUS could be useful for distinguishing PCs from other solid pancreatic lesions.

Background: Diagnostic yield of the current available techniques in patients with upper end common bile duct (CBD) block is low; endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) may be an alternative to evaluate the upper end CBD block. Objectives: To report the outcome of EUS FNA for the evaluation of unresectable proximal biliary strictures. Setting: The study was conducted in a tertiary care center at New Delhi, India. Design: This was a prospective cohort study. Intervention: EUS FNA of unresectable proximal biliary lesion or the suspicious metastatic nodes. Outcome: Performance of EUS FNA in the evaluation of unresectable proximal biliary hilar lesions. Results: A total of 123 patients underwent EUS for the evaluation of upper end CBD block. Eighty-three patients were suspected to have unresectable upper end CBD lesion, and EUS FNA was attempted in these patients. Final diagnosis was based on positive cytology, surgical specimen, and at least 1-year follow-up. Final diagnosis was malignancy in 75 patients and benign stricture in eight patients. EUS FNA was positive for malignancy in 68 out of 75 patients, and none of the patients with benign stricture showed malignancy in FNA specimen (sensitivity 90.66%, specificity 100%, positive predictive value 100%, and negative predictive value 53.33%). Strength: Large sample size. Limitation: Inclusion of both cholangiocarcinoma and gall bladder cancer patients. Conclusion: EUS FNA is highly sensitive tool for malignant lesions involving the upper CBD; low negative predictive value suggests that negative lesions need further evaluation.

Background and Objectives: Pancreatic cystic neoplasms are being increasingly recognized. Endoscopic ultrasonography (EUS) is often required to resolve diagnostic dilemma. Our objective was to study relative proportion, type, and usefulness of EUS for cystic neoplasms in our center. Methods: We reviewed the database of patients registered in our pancreas clinic and those who underwent EUS examination for pancreatobiliary diseases. Pancreatic pseudocyst/walled-off necrosis was excluded. We assessed location, size, number, and cyst characteristics. Diagnostic aspiration was done if the findings were equivocal. Results: Of 2632 new patients registered in the pancreas clinic over 5 years, 94 (3.6%) patients had pancreatic cystic neoplasms which accounted for 12.7% of 737 EUS examinations for pancreatobiliary diseases. The mean age of patients with cystic neoplasms was 48.1 ± 15.2 years; 54 of them were females. The mean size of cyst was 2.7 ± 1.7 cm. Most patients were asymptomatic. The type of cystic lesions was intraductal papillary mucinous neoplasm (IPMN; n = 35), serous cystadenoma (n = 18), mucinous cystic neoplasm (MCN; n = 12), solid pseudopapillary epithelial neoplasm (SPEN; n = 9), cystic degeneration of other tumors (n = 4), simple cyst (n = 4), infectious (n = 2), and unclassified (n = 10). MCN and SPEN occurred exclusively in females. The most common site was head/uncinate (n = 42), followed by body (n = 21), tail (n = 20), neck/genu (n = 6), and multiple (n = 5). Majority of neoplasms did not have high-risk features of malignancy. Conclusions: Cystic neoplasms are increasingly being referred for EUS as a problem-solving tool, most common being IPMN. Absence of high-risk features on EUS reassures both patients and referring doctor.

Background and Objectives: Endoscopic ultrasonography (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) characteristics of common types of pancreatic cystic lesions (PCLs) although identified lacks external validation and surgical histopathology was available in a minority of subjects. We sought to externally validate EUS-nCLE images for differentiating PCLs in a larger series of subjects with a definitive diagnosis. Methods: Six expert endosonographers, blinded to clinical data, reviewed nCLE images of PCLs from 29 subjects with surgical (n = 23) or clinical (n = 6) correlation. After 2 weeks, the assessors reviewed the same images in a different sequence. The performance characteristics of nCLE and the kappa-statistic for interobserver agreement (IOA, 95% confidence interval [CI]) and intraobserver reliability (IOR, mean, standard deviation [SD]) for the identification of nCLE image patterns were calculated. Landis and Koch interpretation of kappa values was used. Results: A total of 29 (16 mucinous PCLs, 13 nonmucinous PCLs) nCLE patient videos were reviewed. The overall sensitivity, specificity, and accuracy for the diagnosis of mucinous PCLs were 95%, 94%, and 95%, respectively. The IOA and IOR (mean, SD) were κ = 0.81 (almost-perfect), 95% CI 0.71–0.90 and κ = 0.86, 0.11 (almost-perfect), respectively. The overall specificity, sensitivity, and accuracy for the diagnosis of serous cystadenomas were 99%, 98%, and 98%, respectively. The IOA and IOR (mean, SD) for recognizing characteristic image pattern of serous cystadenomas were κ = 0.83 (almost-perfect), 95% CI 0.73–0.92 and κ = 0.85, 0.11 (almost-perfect), respectively. Conclusion: EUS-nCLE can provide virtual histology of PCLs with a high degree of accuracy and inter- and intra-observer agreement in differentiating mucinous versus nonmucinous PCLs. These preliminary results support larger multicenter studies to evaluate EUS-nCLE.

Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) and palliative biliary stenting are an established therapy for malignant biliary obstruction that is unsuitable for curative surgery. In ERCP failure, EUS-guided biliary drainage (EUS-BD) procedures are evolving alternative endoscopic techniques. Methods: This was a retrospective analysis of patients who underwent EUS-BD. Results: There were 16 patients who underwent EUS-BD in the last 5 years. Male to female ratio was 9:7. Mean age was 63.56 years. Seven patients had carcinoma pancreas; six had periampullary carcinoma and one patient each had duodenal carcinoma, carcinoma colon with infiltration, and hepatocellular carcinoma with hepatic duct stricture. Indication for EUS-BD was inaccessible ampulla in ten, unidentified ampulla in one, failed biliary cannulation in four, and proximal migration of biliary plastic stent in one. Fifteen (93.75%) underwent EUS-guided choledochoduodenostomy (EUS-CDS), while one had EUS-guided hepaticogastrostomy (EUS-HGS). Covered biliary self-expandable metallic stent was used for EUS-CDS and Giobor biliary stent for EUS-HGS. The procedure was technically successful in all. There were no major immediate postprocedure complications. There was significant symptomatic and biochemical improvement in all. Thirty-day survival was 100%. Conclusion: In malignant biliary obstruction with failed ERCP, EUS-guided bile duct drainage has a high potential as an alternative biliary decompression procedure.

Background and Objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an acceptable option for patients with failed endoscopic retrograde cholangiopancreatography (ERCP). However, it is not known that which of the multiple EUS-BD procedures is most appropriate in a given situation. Attempts at an algorithmic approach are hampered by sparsity of data about transpapillary procedures such as EUS-rendezvous (EUS-RV) and EUS-antegrade (EUS-AG) although published algorithms favor them over transluminal methods (choledochoduodenostomy or hepaticogastrostomy) as the first choice. To analyze factors influencing technical success of EUS-guided transpapillary stent placement through EUS-RV and EUS-AG procedures. To develop an algorithm for EUS-BD based on the results. Methods: Data were collected retrospectively from two centers (India and Japan) over a 7-year period from 2009 to 2016. Records of patients who underwent transpapillary stenting via EUS-AG and EUS-RV procedures following a failed ERCP were entered in a uniform database. Collected data included procedural details, technical success, outcomes, and follow-up. Factors affecting technical success were analyzed by multivariate analysis. An algorithm was developed based on these results. Results: A total of 197 patients underwent transpapillary stenting in the defined period (127 EUS-RV and 70 EUS-AG). Technical success was achieved in 181 patients (91.8%). There were 16 adverse events (8.1%). These included pancreatitis (2.5%), bile leak (2.5%), perforations (0.5%), and bleeding and cholangitis (1% each). One patient died in the EUS-RV group (0.5%). There was no significant difference in success and adverse events of EUS-RV and EUS-AG (success 92.9% vs. 90% P = 0.58, adverse events 7% vs. 10% P = 0.24). On multivariate analysis, common bile duct diameter was the only significant factor affecting success (t = 2.2. P = 0.029).

Objectives: To study the efficacy of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for attaining tissue from distal CBD masses and comparing it to endoscopic retrograde cholangiopancreatography (ERCP)-guided brush cytology from mass. Methods: Fifty-six cases with distal bile duct mass with obstructive jaundice in the last 3 years were taken for the study. First EUS was done with a linear echoendoscope, mass was identified, FNA was performed with a 25-gauge needle making at 2–5 passes, and then material was sent for cytology. The same patients then subjected to ERCP and brush cytology was taken making 2–3 passes. Results: Cases 56, age range 57.2+/-13.6, 40 males, mean serum bilirubin 9 mg/dl, mean size of mass 12 mm (7-30mm). Mean number of passes with fine needle aspiration (FNA) needle was 2.5 (2–5 passes). Mean number of passes with cytology brush was 2 (2–5). Positive diagnosis obtained with FNA was 47 (83.9%). Positive diagnosis obtained by brush was 34 (60.7%). Positive diagnosis was reached in more patients with FNA compared to cytology ( malignancy 80.8% vs 67.6%, suspicious for malignancy 10.6% vs 20.5%, and benign 8.5% vs 8.5%). Conclusions: EUS FNA is a very effective method for diagnosis of distal bile duct masses. Its efficacy is better than ERCP-guided brush cytology. Even small masses are amenable to FNA using EUS guidance. Male over 57 years with jaundice and distal bile duct obstruction has a very likelihood of have a distal CBD cholangiocarcinoma.

Objectives: To study and characterize pancreatic masses using endoscopic ultrasound (EUS) with fine needle aspiration (FNA) and prove that not all pancreatic masses are malignant and require surgery. Methods: A total of 142 cases with pancreatic masses were studied with EUS FNA. FNA was done with a 22-gauge needle for lesions in the body and tail and 25-gauge needle from the duodenum. Results: Age 42+/-15.3 Sex Male: Female: 95:47 Location: head-68, body and neck-38, uncinate-26, tail-10. Echo characteristics: hypoechoic-82, hyperechoic-15, mixed solid and cystic-45 (areas of necrosis). Size 4.6+/-3.9 cm. Cytology: ductal adenocarcinoma-77 (54.2%), nonmalignant (inflammatory)-14 (9.9%), neuroendocrine tumors (NETs)-13 (9.1%), tuberculosis-10 (7.1%), solid pseudopapillary tumors (SPTs)-10 (7.1%), walled-off necrosis-11 (7.7%), mucinous adenocarcinoma-03 (2.1%), diagnosis not reached on FNA-04 (2.8%). Complications: Mild pancreatitis in two cases. No infection or major bleed was noted in our series. Discussion: Not all pancreatic tumors are malignant. Inflammatory lesions in chronic pancreatitis are common. Tuberculosis in India should be thought of. NET and SPT are most common in females and majority in body and tail. Conclusion: All pancreatic tumors are not ductal adenocarcinomas. A large differential diagnosis is seen in studies. Therefore, it would be worth to sample these lesions before subjecting them to major pancreatoduodenal resections as the management plan or the surgical approach would be altered depending on the cytological diagnosis achieved. EUS FNA is a very good option with minimal risk to give a tissue diagnosis before planning surgery.

Background: Endoscopic ultrasonography (EUS) is frequently being performed when common bile duct (CBD) dilatation is detected on cross-sectional imaging without identifiable causes. Objectives: To assess the diagnostic yield of EUS in patients with inconclusive cause of CBD dilatation detected by cross-sectional imaging. Methods: This was a retrospective review of patients with dilated CBD on either computed tomography (CT) or magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) without definite cause undergoing EUS during 2008–2015. Results: A total of 131 patients were recruited (mean age 63, 47% males). The mean diameter of CBD on CT or MRI/MRCP was 12 mm. The etiology of CBD dilatation was identified in 88/131 (67%) patients. Among these, 47% had malignant obstruction with distal cholangiocarcinoma being the most common cancer (51%), 27% had bile duct stone, and 26% had benign stricture. EUS offers an accuracy of 98% in the detection of pathological CBD dilatation. In addition, it is 100% accurate for CBD stone detection, 93% accurate for both malignant and benign obstruction, and 100% specific in cases of nonpathological CBD dilatation. Multivariate analysis indicated that male gender, serum glutamic-pyruvic transaminase = 3 × upper limit of normal (ULN), alkaline phosphatase (ALP) = 3 × ULN, and intrahepatic duct (IHD) dilatation were predictors of pathological obstruction with the odds ratio of 5.46, 5.02, 4.63, and 4.03, respectively. In contrast, ALP = 2 × ULN, female gender, and no IHD dilatation were predictive of nonpathological CBD dilatation with the odds ratio of 7.15, 5.18, and 4.12, respectively. Conclusion: EUS is essential in the evaluation of CBD dilatation in inconclusive CT or MRI/MRCP and thus should be performed routinely when clinically or biochemistry indicative of pancreatobiliary diseases.

Background and Objectives: Obscure dilated common bile duct (CBD) is not uncommon. Endoscopic ultrasound (EUS) has made diagnosis possible in most cases. Data on epidemiology on this entity are scarce. Methods: This was a retrospective study conducted at GIPMER, New Delhi, between January 2014 and May 2015. Data of patients with obscure CBD dilatation were collected. Spectrum of diagnosis, baseline liver function tests (LFTs), radiological features (magnetic resonance cholangiopancreatography [MRCP]), and EUS findings were analyzed. Results: Sixty patients (47 females) with mean age of 52 years (+/-14) were included. Thirty-one had abnormal LFT. Mean CBD diameter on MRCP was 9.8 mm. Pancreatic duct was dilated in five patients. EUS evaluation was helpful and made or predicted diagnosis in all patients. All diagnoses were confirmed on EUS-guided fine needle aspiration cytology (FNAC) or endoscopic retrograde cholangiopancreatography (ERCP) and follow-up EUS in few patients. Diagnosis was passed out CBD stone in 12 (20%), CBD stone in 9 (15%), periampullary diverticulum in 9 (15%), postcholecystectomy dilated CBD in 7 (11.7%), and malignancy in 8 (13.3%). The presence of intrahepatic biliary radicle dilatation (IHBRD) on radiological investigations was significant predictor (P = 0.04) for abnormal EUS findings. EUS saved ERCP and surgery in 25 patients. Conclusion: EUS is an excellent tool for obscure CBD dilatation. The presence of IHBRD predicts abnormal findings EUS.

Background and Objectives: Endoscopic ultrasound (EUS) is considered as the most reliable, accurate test in the detection of pancreatic masses, in whom a need for early, accurate detection, and confirmation of neoplasm is important, at the same time avoidance of surgery. Materials and Methods: This was a prospective study of EUS and fine needle aspiration (FNA)/fine needle aspiration biopsy in patients with pancreatic mass between January 2014 and 2017 at Gandhi Hospital, a tertiary government hospital in the state of Telangana. At the time of EUS size, echo characteristics of lesions, vascularity, lymph nodes (LNs) were noted. In 22 patients, 22-gauge, and in 3 patients, 25-gauge were used. Results: Male to female ratio was18:7, with mean age of 54 years. All had pain abdomen - 100%, mass per abdomen - 5, jaundice, vomiting - 3, and hypoglycemic attacks - 2 (8%). 14 (56%) had lesion in head, 3 - head and body, 2 - isthmus, and 5 - body and tail. Metastasis to LN and liver in 2 (8%). FNA results: Adenocarcinoma - 5 (25%), papillary adenoma - 1 (4%), serous cystadenoma - 1 (4%), mucinous cyst adenoma - 1 (4%), insulinoma - 1 (4%) each, gastrointestinal stromal tumor - 2 (8%), atypical cells - 4 (16%), neuroendocrine tumor - 2 (8%), negative for malignancy - 6 (24%). Minor hemorrhage and abdominal pain were noted in three. All positive and atypical cells patients treated accordingly. All negative cases were followed. Conclusion: EUS is a safe, reliable method in the diagnosis of pancreatic mass in providing accurate cytological diagnosis and exact location of small lesions.

The main portal vein bifurcation occurs near the liver hilum. Both the branches travel in the transverse fissure of liver. The bifurcation lies in an imaginary transverse plane in the transverse fissure, in which the left portal vein is at a higher level than the right portal vein and the left portal vein has a longer extrahepatic course (~2/3^rd of transverse fissure) as compared to the right portal vein (~1/3^rd of transverse fissure). The right portal vein divides into two branches after entering the liver. The imaging of portal vein branches can be done from three stations: abdominal part of esophagus and stomach, duodenal bulb, and descending duodenum. The imaging of portal vein branches is significantly aided by following the fissures of liver. The imaging from stomach keeps the focus of imaging around the left sagittal fissure, where the left portal vein is present; the imaging from duodenal bulb keeps the focus of imaging around the transverse fissure, where the main portal vein is present; and the imaging from descending duodenum keeps the focus of imaging around the right sagittal fissure, where the right portal vein is present. Following the fissure from one part to other is possible by clockwise and counterclockwise rotation and allows the imaging of different parts of portal vein. The imaging from the abdominal part of esophagus and stomach is the most convenient station of imaging for most operators.

Pancreatic tuberculosis is a rare condition even in countries where tuberculosis is endemic. Presentation as a discrete mass may mimic pancreatic neoplasm and therefore warrants thorough investigation. Diagnosis may require histology and culture. We present a case of pancreatic tuberculosis diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). A 22-year-old male was admitted due to 2-month history of epigastric pain, early satiety, and weight loss. Abdominal computed tomography scan revealed a multilocular lesion measuring 6.6 cm × 8.9 cm × 6 cm located at the head of the pancreas. EUS-FNA of the lesion was performed and cytology did not show any malignant cells. Culture for acid-fast bacilli was positive for Mycobacterium tuberculosis susceptible to isoniazid, rifampicin, pyrazinamide, and ethambutol. Antimycobacterial therapy was started and the patient subsequently reported a significant symptom relief. This case illustrates the utility of EUS-FNA as a method for diagnosis of pancreatic tuberculosis. Accurate diagnosis is needed to avoid unnecessary laparotomy. Pancreatic tuberculosis should be included in the differential diagnosis of a pancreatic mass, especially in endemic areas.

Background and Objectives: Ascaris lumbricoides is a common cause of acute pancreatitis in the developing countries. Ultrasonography (USG) is a useful tool for the diagnosis; however, the diagnosis may be false negative in up to 30% of cases. Materials and Methods: During a study period of 10 years, 15 cases of pancreatic ascariasis were diagnosed by USG/endoscopic ultrasound (EUS). Thirteen patients presented with symptoms of acute pancreatitis. Of 13 patients, nine presented with first episode of idiopathic pancreatitis while four presented with idiopathic recurrent acute pancreatitis. One patient had biliary colic and one patient presented with acute cholangitis. Twelve patients had mild pancreatitis while only one had moderate pancreatitis. Only two cases were diagnosed with USG while 13 patients were diagnosed with EUS. The patients underwent side viewing endoscopy/endoscopic retrograde cholangiopancreatography under the same sedation after EUS if EUS revealed biliary/pancreatic ascariasis. Of 15 patients, 14 underwent side viewing endoscopy with removal of live single/multiple worms with rat tooth forceps/Dormia basket in 13 patients. Two patients were managed conservatively with repeat USG showing the absence of ascariasis. There were no complications. Results: EUS features were single or multiple linear hyperechoic structure without acoustic shadowing in the pancreas divisum with central anechoic tube representing alimentary canal of the worm. Live roundworms were removed from papilla without undertaking sphincterotomy. In endemic areas, sphincterotomy facilitates the risk of migration of worms into the common bile duct. Conclusions: Ascariasis-induced acute pancreatitis is mild and EUS is the investigation of choice. The recurrence is rare and treatment is side viewing endoscopy with removal of worms.

Background and Objectives: Endoscopic ultraendosonography (UES) is a sensitive technique for the diagnosis of choledocholithiasis. Our study aimed to determine the positive predictive value (PPV) of UES for the detection of choledocholithiasis. Methods: We performed a descriptive, retrospective, prospective observational, analytical study, with 150 patients who met the inclusion criteria. Endosonography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in the Union of Surgeons Clinical Presentation of the city of Manizales; statistical analysis was performed using the SPSS version 21 program. Results: Fifty-five patients (36.7%) were male and 95 (63.3%) were female. Of the 150 patients positive for choledocholithiasis by UES, 29 of them (19.3%) had images compatible with the presence of bile clay, with 28 patients corroborated in ERCP, with a PPV of 96.6%. As for choledocholithiasis, it was corroborated in 139 patients in ERCP for a PPV of 92.7%. Conclusion: Endosonography has a high valor preditivo positivo for the detection of calculi and mud in the bile duct, being useful in the diagnosis of choledocholithiasis, due to its sensitivity for the detection of microlithiasis (<3 mm calculi and biliary mud), minimal invasion, and scarce morbidity, compared to other diagnostic techniques such as magnetic resonance neurography.

A 60-year-old North Indian female presented with recurrent dull-aching right upper quadrant pain of a month duration. Investigations showed the presence of anemia, raised erythrocyte sedimentation rate, and azotemia (serum creatinine 2.5 mg%). Noncontract computed tomography scan demonstrated a 5 cm × 5 cm hypodense mass lesion at porta. Endoscopic ultrasonographic (EUS) examination revealed a well-defined rounded 6 cm × 6 cm hypoechoic periportal mass without any vascular invasion, fine needle aspiration (FNA) showed sheets of atypical plasma cells and plasmablasts with eccentric nuclei, 1–2 prominent nucleoli, and abundant basophilic cytoplasm; some of the cells show the characteristic pale perinuclear “hof”. Bone marrow biopsy showed hypercellular marrow with proliferation of atypical plasma cells comprising 80% of the cellularity with reduced normal hematopoietic elements. There was a sharp M band in the gamma region of 4.7 g/dl, on serum protein electrophoresis and an elevated IgG kappa-free light chain of 1590 mg/dL. All these findings were consistent with multiple myeloma with periportal plasmacytoma. Hemato-oncology Department was consulted and she received bortezomib-based therapy. On follow-up after 4 months, M band in the gamma region decreased to 0.6 g/dl and kappa-free chain decreased to 18.7 mg/dl on serum electrophoresis. Anemia improved and serum creatinine decreased to 1.3 mg/dl. Repeat EUS revealed a decreased of porta mass to 1.5 cm × 1.5 cm. This case highlights the role of EUS FNA in solving the clinical mystery and helps in reaching the final diagnosis and providing the appropriate treatment.

Background: Ascaris lumbricoides infestation is endemic in tropical countries. Most infections are asymptomatic, but it can produce a wide spectrum of manifestations including hepatobiliary and pancreatic complications. Biliopancreatic ascariasis is rare outside the endemic regions. Case Report: We report a case of recurrent pancreatitis, symptomatic for the last 2 years, multiple hospitalizations, various imagings with ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography failed to establish the etiology, and endoscopic ultrasound revealed an adult A. lumbricoides worm inside the main pancreatic duct. The patient underwent endoscopic retrograde cholangiopancreatography with extraction of the dead worm; deworming was done with albendazole 400 mg, single dose. Patient is symptom-free for the last 1 year. Discussion and Conclusion: Biliary ascariasis is a common occurrence in endemic regions and is causally associated with biliary colic, acute cholangitis, acute pancreatitis and its complications, recurrent pyogenic cholangitis, acute cholecystitis, and liver abscess. Secondary to smaller duct diameter, migration of A. lumbricoides into the pancreatic duct is uncommon. Even in highly endemic areas such as Kashmir, India, pancreatic ascariasis was rare and represented only 1.4% of all hepatobiliopancreatic ascariasis. Endoscopy ultrasound is a useful modality in diagnosis and management of patients with pancreatic ascariasis.

Background: Pancreatic tuberculosis is an uncommon disease, presenting as hypoechoic mass on imaging mimicking malignancy. Consequently, it represents a diagnostic challenge necessitating a tissue diagnosis. Case Report: A 75-year-old female presented with progressive jaundice and weight loss; imaging with computed tomography (CT) showed a large (5.8 cm × 4.6 cm) pancreatic head mass with encasement of portal and superior mesenteric veins, peripancreatic nodes, atrophic pancreatic parenchyma, and dilated main pancreatic duct. Cancer antigen 19-9 was moderately elevated. With a diagnosis of inoperable pancreatic malignancy, she was planned for tissue diagnosis and palliative chemotherapy. Endoscopic ultrasonography (EUS) showed a heterogeneous mass with vascular invasion as in the CT. Fine needle aspiration (FNA) and biliary decompression with a plastic stent performed in the same sitting. Cytology demonstrated granuloma with caseous necrosis and presence of acid-fast bacilli. Antituberculosis treatment was started, and repeat CT after 6 months showed resolution of the mass. Discussion and Conclusion: A diagnosis of isolated pancreatic tuberculosis is rare and is difficult by clinical presentation alone; in India, it should be considered as a differential diagnosis of a pancreatic tumor. Benign lesions can also present with vascular invasions mimicking inoperable malignancy. EUS FNA is a very useful tool in accurate diagnosis of pancreatic head mass avoiding unnecessary surgeries.

Background and Objectives: Pancreaticobiliary ascariasis is common problem in tropical countries. The roundworm in the bile duct can cause biliary colic, obstructive jaundice, or pancreatitis. Live Ascaris worms are usually diagnosed on ultrasonography (USG) or endoscopic ultrasonographic (EUS) showing characteristic features of linear mobile echogenic structure with central anechoic lumen. However, the worm can die inside the common bile duct (CBD) and create a foreign body acting as a nidus for stone or sludge formation. Obstructive jaundice due to dead Ascaris is a rare but important cause in the developing World. As the worm shrivels up after death, accurate identification requires a high index of suspicion. The features of dead worm on EUS include hyperechoic structure without any acoustic shadow. Methods: We present a case of a 2-year-old Indian female child referred with biliary colic and jaundice for the last 3 weeks. Abdominal USG revealed multiple ill-defined, oval, hyperechoic shadows near the lower end of dilated CBD. MRCP showed multiple intraluminal curvilinear, hypointense areas in lower CBD. Results: Linear EUS from the duodenal bulb revealed dilated CBD with multiple hyperechoic structures without acoustic shadowing. It showed 2–6 mm sized curvilinear, disc-shaped, short-segment echogenic structures with central anechoic core parallel and equidistant from each other, suggestive of recently broken down parallel fragments of round worms. The central anechoic core represents the digestive tract of Ascaris. After multiple balloon sweeps on ERCP, creamy white structures and yellow-colored material were removed suggestive of recently fragmented Ascaris. Conclusions: Biliary ascariasis should be considered in any child presenting with obstructive jaundice in endemic regions.

A 34-year-old male presented with weight loss of 10 kg in the last 3 months. There was no abdominal pain, fever, jaundice, or gastrointestinal bleeding. On routine laboratory investigation, there was microcytic anemia with hemoglobin of 8.5 g/dl. On ultrasound examination, there were abdominal lymph adenopathy and left adrenal enlargement. Endoscopic ultrasound was done which revealed multiple hypoechoic lesions in liver; abdominal lymphadenopathy and bulky left adrenal fine needle aspiration were taken from periportal lymph node and adrenal using a 22-gauge needle; cytopathology report was suggestive of neuroendocrine tumor, Grade 2. A DOTA scan was done for defining extent which revealed DOTA avid lesion in the right middle lung, mediastinal and abdominal lymph nodes, multiple liver space-occupying lesions, and bilateral bulky adrenal. He was finally diagnosed as lung neuroendocrine tumor with disseminated metastasis.

A 17-year-old male presented with weight loss. Computed tomography (CT) of the abdomen was suggestive of pancreatic head mass lesion with dilated pancreatic duct and common bile duct. He underwent endoscopic retrograde cholangiopancreatography with stenting outside for jaundice. A positron emission tomography CT was done which showed pancreatic lesion with abdominal lymph nodes. Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) from pancreatic lesion and lymph node revealed anaplastic lymphoma. Thus, EUS-guided FNA provided correct diagnosis and prevented surgery. The patient received chemotherapy and improved.

Background: There is an increasing role for endoscopic ultrasound (EUS) in the treatment of pancreatic tumors. Here, we describe a case of a multifocal insulinoma treated with two ablation modalities. Case Report: A 62-year-old gentleman was diagnosed with multiple endocrine neoplasia type I since 1993. A distal pancreatectomy was done previously for insulinoma. He was noted to have recurrent hypoglycemia since 2015, with a glucose level range of 2.3–3.0 mmol/L. A computed tomography of the pancreas showed two pancreatic nodules at the head (0.8 cm) and body (2 cm). A diagnosis of recurrent insulinoma was made. He was treated with diazoxide but only partially responded to therapy. As he was not keen for surgery, we proceeded to perform EUS-guided ablation therapy. The decision was made to ablate the body lesion with radiofrequency ablation (RFA) but the head lesion with ethanol as it was technically difficult to perform RFA for lesions in the head due to the stiffness of the RFA probe. 1.5 ml of absolute ethanol was injected into the 8 mm lesion at the head of pancreas using a 22-gauge Expect^™ needle (Boston Scientific). An 18-gauge (1.7 mm tip diameter) RFA probe EUSRA^™ using “continuous mode” of 50 watts, VIVA Combo^™ RF System (TaeWoong Medical) was applied to a 2 cm lesion at the body of pancreas. There were no peri/post-operative complications. After 2 weeks postablation, there was marked improvement. He was no longer hypoglycemic with a fasting glucose level of 5.3 mmol/L. Conclusions: There appears to be a promising role for EUS-guided ablation of small pancreatic tumors. However, larger studies are needed to evaluate the long-term outcome of the procedure.

Background and Objectives: About 80% of patients with gallbladder cancer present with pain. Unlike cancer pancreas, endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) for pain relief has not been studied in gallbladder cancer. We studied the effect of EUS-CPN in gallbladder cancer and whether it has any effect on decreasing analgesic dose requirement. Methods: Patients with unresectable gallbladder with pain severity = 3 on visual analog scale (VAS) in spite of nonsteroidal anti-inflammatory drugs and/or weak opioids underwent EUS-CPN over 1-year period. They were followed prospectively for 8 weeks; pain severity and analgesic dose requirement were assessed at baseline and weeks 2, 4, and 8. Response was defined as complete, partial, and no response if pain severity on VAS was 0, decreased by = 3, and decreased by <3, respectively, as compared to baseline. Results: CPN was successfully done in 19 out of 21 included in the study. Median pain severity on VAS was 7, 2, 4, and 5 at baseline and weeks 2, 4, and 8. At week 2, 3 (15.8%), 15 (79%), and 1 (5.2%) had complete, partial, and no response, respectively; at week 4, none, 12 (63.2%), and 7 (36.8%) had complete, partial, and no response, respectively; and at week 8, none, 11 (58%), and 8 (42%) had complete, partial, and no response, respectively. Median number of paracetamol + tramadol tablets/day in gallbladder cancer was reduced to 2, 2, and 3 tablets/day on week 2, 4, and 8, respectively, from baseline three tablets/day (P = 0.016). None had any procedure-related adverse events. Conclusion: EUS-CPN provides short-term partial pain relief in about 60-70% of patients.

Background and Objectives: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is one of the advance therapeutic EUS procedures that require a learning curve. Several training models and biliary duct prototype have been developed, but each has its own merits and limitations. The authors have created a mixed gelatin model with three-dimensional (3D) bile ducts that is feasible, realistic, durable, and inexpensive. Material and Methods: The models combined with a mixed-gelatin material and 3D printing of different type biliary systems. They are applicable for multiple usage during training in punctures, aspirations, stents placement, and removal technique. Evaluation of the models regarding its overall applicability, quality of EUS images, and four steps of EUS-BD procedure (needle puncture, guidewire manipulation, tract dilation, stent placement) was noted. Results: A single mixed gelatin model can be applied at least four punctures with sustainable good quality. Preliminary surveys demonstrated that good ratings such as bile duct can be identified clearly, and needle puncture, dilate, and stenting can be performed with realistic resistance feeling. The echogenicity and ultrasonography imaging were comparable to human visceral organs. In addition, there was no need to concern about hazard control and dangers from animal-related disease. Conclusion: A 3D printing bile duct with mixed gelatin model for EUS-guided biliary drainage is cost-effective, feasible, realistic, and safe

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an acceptable rescue option in patients with failed endoscopic retrograde cholangiopancreatography (ERCP). EUS-guided biliary rendezvous (EUS-RV) allows transpapillary drainage in patients with failed ERCP and approachable papilla. There are limited learning and training opportunities for EUS-guided biliary drainage (EUS-BD) and EUS-RV at most centers due to low case volumes. An effective and easily reproducible model is desirable Objectives: To develop and validate a model for stepwise learning of EUS-BD and EUS-RV. Methods: A hybrid model was created utilizing pig esophagus and stomach, synthetic duodenum, and synthetic biliary system with distal stricture. Twenty-eight trainees were given hands-on training in EUS-BD and EUS-RV procedures. They were assessed for objective criteria (needle puncture, contrast injection, and guidewire manipulation across hilar bifurcation, stricture, and papilla, followed by guidewire retrieval with snare into the duodenoscope channel and stent placement). Results: All trainees could complete the requisite steps of EUS-BD and EUS-RV in a mean time of 11 min (8–18 min). Twenty trainees had technical issues during the procedures, which were corrected by the expert (wrong scope position 4, incorrect duct puncture 8, guidewire manipulation 8). At 10 days follow-up, 9 of 28 trainees had successfully performed three EUS-RV and seven EUS-BD procedures independently at their respective institutes. Conclusions: The Mumbai EUS II hybrid model gives real-life feel of situations encountered during EUS-RV and EUS-BD.

Background and Objectives: Endoscopic ultrasound (EUS)-guided biliary drainage is novel technique for biliary drainage after failed ERCP. The aim of the present study is to report the outcomes of EUS-guided biliary drainage after failed ERCP due to inaccessible papilla due to duodenal infiltration. Methods: Data of all the patients who underwent choledochoduodenostomy form April 2014 to September 2016 were collected. Suprapancreatic common bile duct (CBD) was punctured transduodenally with a 19-gauge needle, needle tract was dilated using 6F cystotome, and a fully covered self-expanding metal stent was placed into the CBD. Complications during procedure and follow-up were recorded. Results: Ten patients underwent EUS-guided choledochoduodenostomy. Seven patients had pancreatic cancer, two had carcinoma gall bladder with mid CBD block by metastatic lymph nodes, and one had ampullary carcinoma. Mean bilirubin was 16.4 mg/dL (± 3.2 mg/dL). Procedure could be performed successfully in all ten patients. Jaundice improved in all the patients, except one who had liver metastasis. No procedure-related complication was noticed. Bilirubin decreased to 1.8 mg/dl (± 1.4 mg/dL) at 1-month follow-up. After a mean follow-up of 8 months (± 2 months), survival was 70%, three patients died of underlying malignancy, one patient had stent migration in duodenal lumen, which was taken out, and plastic stent placed through the patent choledochoduodenal fistula. Conclusion: EUS-guided choledochoduodenostomy is a safe and effective alternative biliary drainage in patients with mid and lower end malignant CBD block.

Background and Objectives: Endoscopic ultrasound (EUS)-guided drainage of symptomatic walled-off pancreatic necrosis (WON) followed by fully covered self-expanding metal stent (FCSEMS) placement offers several advantages such as higher technical success and option of necrosectomy. The aim was to evaluate the safety and efficacy of EUS-guided drainage of patients with WON using FCSEMS and intracavitary lavage with solution containing hydrogen peroxide by adopting a step-up approach. Methods: A prospective open-label study was done at a single tertiary care center from January 2014 to January 2016. Patients with symptomatic WON who underwent EUS-guided drainage followed by FCSEMS placement were included in the study. Primary endpoints were complete drainage with improvement in symptoms or major adverse events. Secondary endpoints were minor adverse events related to procedures. Results: A total of 64 patients (mean age 36 years; 52 males) were included. Technical success was achieved in 100% and clinical success was achieved in 90.6%. Complete drainage was achieved with FCSEMS alone in 18 (28.1%), FCSEMS with necrosectomy using lavage in 40 (62.5%), FCSEMS with percutaneous drainage in 5 (7.8%), and 1 (1.5%) patient required salvage surgery. Major adverse events were life-threatening bleeding in 3 (4.6%). Minor adverse events were nonlife-threatening bleeding in 2 (3.1%) patients and stent migration in 3 (4.6%) patients. Conclusion: EUS-guided WON drainage with FCSEMS followed by necrosectomy with lavage using solution containing hydrogen peroxide as a step-up approach is a minimally invasive and effective method with high technical and clinical success. Patients with solid debris >40% need aggressive management.

Background and Objectives: Endoscopic ultrasound-guided transluminal drainage (EUS-TD) and sequential direct endoscopic necrosectomy (DEN) for pancreatic fluid collections (PFCs) have been reported as a useful treatment. Recently, a new dedicated biflanged metal stent (BFMS) matched to the PFC condition has been developed. Herein, we show the prospectively evaluated clinical outcome of this new BFMS for the treatment of PFCs. Methods: EUS-TD using new stent was performed in 17 patients for PFCs (4 pancreatic pseudocysts; 13 walled-off necrosis). When clinical resolution could not be achieved within a few days after EUS-TD, DEN was performed the following day. Results: New stent was deployed successfully with a median procedure time of 16 min and with no procedure-related adverse events in all the patients. DEN (n = 5) and/or additional drainage procedure (n = 6) through the stent were achieved in all the patients in whom they were attempted (8/8). Stent dislocation during DEN was not observed in any patients, but in one patient, spontaneous stent migration was observed. Two WON patients died from pseudoaneurysm rupture occurring between the endoscopic necrosectomy sessions and from multiple organ failure although hemostasis was achieved by coil embolization. The PFCs in the other 15 patients completely resolved. Conclusions: The new BFMS is technically feasible and safe for the treatment of PFCs.

Background and Objectives: Recently, endoscopic ultrasound-guided pancreatic duct (EUS-PD) drainage and rendezvous technique have been advocated as an alternative for patients after failed ERCP. However, the efficacy and safety of these procedures are still unknown. The aim of this study is to retrospectively evaluate the efficacy and safety of the EUS-PD and rendezvous technique. Methods: Until now, 51 patients with acute recurrent pancreatitis due to main pancreatic duct stricture or stenotic pancreatojejunostomy underwent EUS-PD and rendezvous technique. Results: Fifty-one patient’s characteristics are as follows; 23 males; age range, 9–93 years; median, 60 years. Surgically altered anatomy was in 39 and normal anatomy in 12. Rendezvous method was performed in 13, EUS-PD in 33, pancreatography only in 5. Technical success rate was rendezvous in 68.4% (13/19), EUS-PD in 97.1% (33/34), 90.1% (46/51) totally. Clinical success was achieved in all technically succeeded cases (100%, 46/46). Adverse events were seen in 7.8% (4/51), mild pancreatitis in 1, bleeding in 2, and pancreatic fistula in 1. One bleeding case was needed transcatheter arterial embolization for hemostasis. However, there were no stent migration cases. Conclusions: EUS-PD and rendezvous method are feasible and safely performed without severe adverse effects.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stenting is the first-line biliary drainage in patients with malignant biliary obstruction (MBO). Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided biliary drainage (EUS-BD) are alternative methods. Objectives: To compare efficacy and safety of these three methods as a case–controlled study. Methods: From January 2014 to September 2016, 144 patients were followed for their clinical recurrent biliary obstruction (RBO) or their death or 1-year follow-up. Results: EUS-BD, PTBD, and ERCP were performed in 30, 60, and 54 patients, respectively. Technical success rate (TSR) of EUS-BD was significantly lower than both PTBD and ERCP (84% vs. 100% and 100%, respectively, P < 0.001). PTBD had significantly lower clinical success rate (CSR) than ERCP (65% vs. 85%, respectively, P < 0.001). RBO rates of PTBD were significantly higher than those of EUS-BD and ERCP (52% vs. 17% vs. 13%, respectively, P < 0.001). The survival analysis is not statistically significant among the three methods (P = 0.07, log-rank test). Conclusions: In patients with MBO, ERCP with transpapillary drainage should be selected as the first choice because ERCP provided the high TSR and CSR. EUS-BD and PTBD should be selected as the next alternatives because EUS-BD provided lower TSR and PTBD had lower CSR and higher RBO.

Endoscopic ultrasound (EUS)-guided pelvic abscess drainage though uncommon modality for definite treatment of pelvic abscess is an effective method of treatment for pelvic abscess due to its proximity to rectal wall. We performed drainage of pelvic abscess in a 65-year-old male with uncontrolled diabetes, abscess was measured 78 mm × 77 mm, drainage was performed using two 10 Fr pigtail stents, spontaneous drainage of entire abscess cavity was noted, and the patient was discharged on the same day on oral antibiotics with dramatic improvement in pain, fever, and total leukocyte count. EUS drainage has an advantage of being a day-care procedure; as compared to percutaneous drainage, no discomfort of external catheter and limited mobility are experienced by the patient. Other modalities such as conventional ultrasonography-guided per rectal/vaginal drainage have disadvantage that stent cannot be placed.

Background and Objectives: Interventional endoscopic ultrasound (EUS) includes fine needle aspiration (FNA), pancreatic cystogastrostomy, aspiration of cystic cavity or collection, hepaticogastrostomy, and coiling. It is considered safe. This study was undertaken to note frequency of various complications that arose with interventional EUS at our center. Methods: This was a retrospective cohort study done at a tertiary level referral center. Records of all patients who underwent EUS intervention over a period of 6 years (October 2010 to September 2016) were reviewed. Procedure-related minor adverse events such as throat pain and abdominal pain were noted. Complications were defined as acute pancreatitis, perforation, mucosal tear, hepatic encephalopathy, pneumomediastinum, pneumoperitoneum, peritoneal leak, bleeding, hematoma, and fever requiring hospital admission. Results: A total of 4654 EUS were done, of which 2030 intervention performed. Of these, 1780 were EUS FNA, 146 aspiration, 64 cystogastrostomy, and 40 others. Procedure-related minor adverse events were noted in 42% cases (throat pain - 31% and abdominal pain - 11%). Complications were observed in 35 patients (1.72%); minor mucosal bleeding (12), mild acute pancreatitis (5), asymptomatic duodenal hematoma (4), fever requiring hospitalization (3), duodenal perforations (2), cervical esophageal tear (2), mild hepatic encephalopathy (2), pneumomediastinum (1), pneumoperitoneum (1), bleeding from gastroduodenal artery (1), cystogastostomy site bleeding (1), and peritoneal leak (1). All the complications were managed conservatively except duodenal perforations which required surgery and peritoneal leak requiring drain placement percutaneously. On subgroup analysis, there were significant fewer complications with operator experience of >1000 EUS (P = 0.002). Conclusion: EUS intervention is a safe procedure, especially in experienced hands.

Background and Objectives: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) is an alternative procedure to percutaneous transhepatic biliary drainage for patients with malignant distal biliary obstruction requiring biliary drainage in whom ERCP has failed. We studied technical success, clinical success, stent patency rate, and adverse events in EUS-CD. Methods: It is a prospective study from January 2015 to December 2016. Patients with unresectable, malignant distal biliary obstruction requiring biliary drainage in whom ERCP had failed either because of failed cannulation of papilla or due to duodenal stenosis were included. EUS-CD was done using a 6 cm partially covered self-expanding metal stent. Technical success, clinical success (more than 50% reduction in total bilirubin by week 2), stent patency rate, and adverse events were assessed. Patients were followed up for 3 months. Results: Thirty patients underwent EUS-CD, 20 (66.7%) had failed cannulation of papilla, and 10 (33.3%) had duodenal stenosis. EUS-CD was successfully done in 28 patients; all of those had clinical success. Total bilirubin (in median) decreased from 20 mg/dl to 5 mg/dl by week 2. Four patients (13.3%) had adverse events; two had bile leak, one had hemobilia, and other had stent block due to sludge. None had major adverse events; all adverse events were managed successfully. Five died due to progression of disease within 3 months (range: 40–88 days) with 3-month stent dysfunction-free patency rate of 83.33%. No procedure-related mortality occurred. Conclusion: EUS-CD with a partially covered metal stent has a high technical and clinical success with no major adverse events.

Background: Glue injection of large fundal varices (>2 cm) may be associated with embolic complications. Endoscopic ultrasound (EUS)-guided coiling with or without glue injection may be safe as coil may act as a scaffold to prevent embolization. Objectives: To find out the outcome of sequential treatment with EUS-guided coiling with or without endoscopic glue injection for large fundal varices. Methods: After localization of varix with EUS, transgastric puncture was done with a 19-gauge needle, and 1–5 coils (12 mm) were placed in the varix. If immediate obliteration could not be achieved, EUS was repeated after 24 h. In case of persistent flow, endoscopy and direct glue injection were performed. Result: Ten patients (6 males, mean age 51 years) with large fundal varices and underwent EUS treatment. Nine were cirrhotics (child A:B:C - 2:6:1) and one had extrahepatic portal venous obstruction. All ten patients had recent bleed within 24 h of EUS, and one patient had active bleed during procedure. Mean varix size was 2.5 cm (± 0.4). Coiling was possible in all patients with mean number of coils of 3.6 (range 2–5). Immediate flow obliteration was seen in five patients; repeat EUS the next day showed persistent flow in four patients (40%) who underwent glue injection; mean volume used was 2 ml (range 1.5–3 ml). No symptoms related to embolization occurred, one patient had self-subsiding prolonged fever, and no rebleed occurred at 130 days (range 50–210). Conclusion: EUS-guided coiling with glue injection for large fundal varices is effective and safe.

Background and Objectives: Endoscopic ultrasound-guided hepaticoenterostomy (EUS-HES) has been reported as an alternative to the percutaneous or surgical approach after failed endoscopic retrograde cholangiopancreatography (ERCP). We have performed EUS-HES as a primary drainage in patients with surgically altered upper gastrointestinal anatomy and malignant biliary obstruction without ERCP. The present study aims to evaluate the safety and the efficacy of primary EUS-HES. Methods: A total of seventy EUS-HES were performed at our institution between January 2012 and February 2017, and 26 of these patients with surgically altered upper gastrointestinal anatomy and malignant biliary obstruction underwent EUS-HES for primary drainage. The patients were prospectively enrolled, and the clinical data were retrospectively collected for these 26 cases. An intention-to-treat analysis was used to investigate the technical success rate. Results: The median age was 68 years (male/female 16/10). The technical success rate was 100% (26/26) and clinical success rate was 96.2% (25/26). Early adverse event rate was 15.4% (4/26). Segmental cholangitis were seen in two cases, fever was seen in one case, and reflux esophagitis due to bile reflux was seen in one case. All cases were treated conservatively. Serious adverse events were not seen. The stent dysfunction was seen in ten patients. The causes of stent dysfunction were biliary sludge (n = 11) and distal stent migration (n = 2). In 12 cases, we could reinsert a new stent easily. In only one patient, we chose percutaneous drainage because of general condition turned worse. Conclusions: Primary EUS-HES was safety and useful, especially for avoiding serious adverse events and reintervention.

Background and Objectives: Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts and fluid collections is an important therapeutic procedure. However, this procedure can be technically challenging especially for inexperienced (beginner endosonographer) and requiring a learning curve to obtain good results. Currently, several training models for EUS-guided drainage of pancreatic pseudocysts have been developed, but each has its own merits and limitations. Materials and Methods: The authors have created a gelatin model that is easy and inexpensive to prepare. The materials for preparation are gelatin and corn starch. It is applicable for multiple usage during training in punctures, aspirations, stents placement, and removal technique. It can be cauterized, dilated, and applicable for stent placement. Results: The total cost for one unit model was 10 USD. A single model can be applied at least four punctures with sustainable good quality. Preliminary surveys obtained from users demonstrated good ratings such as target lesion can be identified clearly, and needle puncture, dilate, and stenting can be performed with realistic resistance feeling. The echogenicity and ultrasonography imaging were comparable to human visceral organs. In addition, there was no need to concern about hazard control and dangers from animal-related disease. Conclusion: A new gelatin training model for EUS-guided pancreatic pseudocyst drainage is cost-effective, feasible, realistic, and safe.

Background and Objectives: We evaluated the clinical usefulness of endoscopic ultrasound (EUS) in diagnosing visceral vascular dissection and in assessing morphological and hemodynamic characteristics required for optimized patient management. Methods: EUS was performed in 62 patients with clinically suspected visceral artery dissection as determined by computed tomography scan between February 2012 and December 2016. Conventional B-mode, color Doppler, and contrast-enhanced harmonic-EUS (CEH-EUS) were done to evaluate vascular status of celiac artery and superior mesenteric artery. Results: EUS and CEH-EUS identified all the visceral vascular dissections. Five patients (8%) underwent surgical or radiological intervention, whereas the others were managed conservatively with or without anticoagulation therapy. Vascular stenosis was more severe in patients who underwent surgical or radiological intervention (92% ± 8% vs. 67% ± 20%, P = 0.007). The severe vascular stenosis was associated with surgical or radiological intervention rather than conservative management (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.07–1.68, P = 0.01). The presence of false lumen thrombi (HR 0.24, 95% CI 0.025–2.301, P = 0.22) and collateral circulation (HR 0.30, 95% CI 0.04–2.06, P = 0.22) tended to predict conservative management of visceral vascular dissection without statistical significance. In multivariate analysis, degree of vascular stenosis was the only significant factor predicting surgical or radiological intervention in visceral vascular dissection. Conclusions: EUS may be a promising diagnostic modality to assess the visceral artery dissection without exposure to radiation. Moreover, EUS is a useful tool to determine the appropriate treatment options for patients with visceral artery dissection based on the degree of vascular stenosis.

Background and Objectives: The diagnostic role of endoscopic ultrasound (EUS) in children has been demonstrated only recently. Data on the technique’s therapeutic indications remain scarce. We evaluated diagnostic and interventional EUS indications, safety, and impact in children with pancreaticobiliary disorders. Patients and Methods: We retrospectively reviewed our single pediatric center experience covering a 14-year period. Results: Between January 2000 and 2014, 52 EUS procedures were performed on 48 children (mean age 12 years) with pancreaticobiliary disorders for suspected biliary obstruction (n = 20/52), acute/chronic pancreatitis (n = 20), pancreatic mass (n = 3), pancreatic blunt trauma (n = 7), and ampullary adenoma (n = 2). Positive impact of EUS was observed in 51/52 procedures (98%), precluding using endoscopic retrograde cholangiopancreatography (ERCP) (n = 9), focusing on endotherapy (n = 21), or reorienting therapy toward surgery (n = 7). EUS-guided fine needle aspiration was carried out on 12 patients. Thirteen therapeutic EUS procedures were conducted, nine of which were combined EUS-ERCP procedures (three EUS-guided pseudocyst drainage, one EUS-guided transgastric biliary drainage of a metastatic rhabdomyosarcoma). Conclusions: We report on a large pediatric EUS series for diagnostic and therapeutic pancreaticobiliary disorders, showing a significant impact of diagnostic EUS and affording insights into novel EUS and combined EUS-ERCP therapeutic applications. We suggest considering EUS as a diagnostic and therapeutic tool in the management of pediatric biliopancreatic diseases.

Objectives: To retrospectively analyze 162 cases of walled-off necrosis (WON) treated with only plastic stents in a tertiary referral center in India. Methods and Results: A total of 162 patients of WON underwent endoscopic ultrasound (EUS)-guided drainage with a 19-gauge needle puncture, tract formation with 6 Fr cystotome, dilatation with controlled radial expansion balloon up to 12 mm, placement of two 7 Fr disposable pressure transducer stents, and nasocystic drain. Drain was removed after 48 h, and necrosectomy was done as per the need in 3–5 sessions 48 h apart. Total number of patients was 162; size of the WON was 10.2 cm (6–30 cm); amount of necrosis was 37% (7%–63%); primary procedure was carried out in 24.3 min (17–60 min), first session - 31.6 min (20–55 min), second session - 22.5 min (12–35 min), third session - 14.7 min (10–25 min), fourth session - 12.3 min (7–20 min); technical success of primary procedure was 98.1% (three procedures abandoned). Nasocystic drain - 97 patients (59.8%), necrosectomy–first session - 65 patients (40.1%), necrosectomy–second session - 57 patients (35.1%), necrosectomy–third session - 38 patients (23.4%), necrosectomy–fourth session - five patients (3.1%), bleeding - five cases (three abandoned, two controlled endoscopically), capnoperitoneum - one cases (conservative treatment). Significant infection was seen in seven cases (4.3%), minor 15 cases (9.2%), mortality - 0 cost of plastic stents (2) 35$ in India cost of Nagi Stent 850$ in India. Conclusions: Plastic stents are very effective in WON drainage with achieving clearance in around three sessions and minimal infection. Nasocystic drain helps reduce rate of infection. The procedure is very cost-effective.

Case Report: A 50-year-old woman with a previous choledochectomy and hepaticojejunostomy reconstruction for a Type III choledochal cyst presented with recurrent severe abdominal pain. The computed tomographic scan showed a 1.2 cm calculus within a 3.5 cm remnant choledochus stump. Previous endoscopic retrograde cholangiopancreatography cannulation and precut sphincterotomy had failed to gain access into the choledochus. The remnant choledochus was accessed by endoscopic ultrasound needle puncture followed by a transduodenal placement of a plastic stent. A Nagi expandable metal stent was exchanged for the plastic stent after allowing the choledochoduodenal tract to mature over a few weeks. The Nagi stent was allowed to expand, resulting in the stone dropping out spontaneously within 2 weeks. A sphincterotomy of the major papilla was also performed after an antegrade rendezvous technique. The patient’s symptom subsided after the successful removal of the stone. Conclusion: This case illustrates a novel method of removing a choledochus stump stone.

Background: Pancreatic calculi are sequelae of chronic pancreatitis (CP) and may obstruct pancreatic ducts leading to pain. Indications for endotherapy include nonimpacted <5 mm stones in the head of pancreas with the absence of downstream strictures. The assessment before endotherapy is done by magnetic resonance cholangiopancreatography/computed tomography. Objectives: To assess the modality of endoscopic ultrasound (EUS) as a roadmap before endoscopic retrograde cholangiopancreatography (ERCP) in patients planned for endotherapy in CP. Methods: The data of 412 patients with CP were retrospectively analyzed. A total of 143 were associated with stones in the head/papillary region of pancreas. Of these, around 75 were excluded and remaining 68 were evaluated by EUS using a linear/radial echoendoscope before ERCP. Results: Of 68 cases, 48 were associated with hard stones with acoustic shadowing while twenty were associated with soft stones without acoustic shadowing. In twenty soft stones cases, ERCP was successful in 18 patients. In 48 patients with hard stones, there was failure of endotherapy in forty patients which required extracorporeal shock wave lithotripsy/surgery. The presence of large, hard, immobile stones was negative predictors of successful endotherapy. Small, ampullary/papillary stones were positive predictors. Conclusions: EUS can influence therapeutic decisions before endotherapy and can prevent unsuccessful attempts improving overall success/prognosis. EUS has an additional advantage of making a diagnosis of ampullary/papillary stones and biliary obstruction which can be treated endoscopically. It can guide whether endotherapy needs to be performed through major or minor papilla. EUS by diagnosing pancreatic tumor/strictures missed on other imaging modalities allows early surgical reference and hence improves long-term prognosis.

We present a biliary derivation from the gastric body in a patient with subtotal gastrectomy and anastomosis type Billroth I. The patient had a tumor obstruction of distal coledoco. The patient was with ictericia and the examinations indicated obstructive patron. A gastric transluminal derivation is made to common hepatic. Steps are as given below:

1. Endosonography that locates the tumor obstruction of the coledoco shows the dilated hepatic conduct;
2. Doppler signals are made that discharge vessels in the puncture route;
3. The punction was made in gastric body with endosonographic window direct to the dilated common hepatic conduct. The puncton is performed with Boston Scientific 19-gauge needle;
4. Bile was aspirated and contrast was injected to delineate the anatomy;
5. We pass a hydrophilic guide of W. Cook 0.035 mm and after introduce a cystotomy of 6 Fr;
6. Dilated the track is passed an autoexpandible stent covered of 60/10 mm.

Patient evolves satisfactorily.

We present the technique of transluminal coledocoduodenostomy for a distal tumoral injury of biliary tract and pancreas that was not permitted to perform CPRE. Our technique by steps is shown in the video, explaining with drawings and video which is performed. Steps:

1. Place the linear endosonograph in DI;
2. Locate the distal point dilated from the coledoco;
3. We do Doppler to discover vessels that interpong between the transducer and the biliary tract;
4. We make a punction in this case with Boston Scientific needle 19-gauge;
5. After the biliary punction, we suck to check that there is bilis;
6. Contrasting to draw the biliary route in its entirety and planning the type of stent;
7. We introduce a hydrophilic 0.035 Terumo guide;
8. Through this, we pass a cystotomy of W. Cook 6 Fr;
9. In this way, we dilate the tract between the duodenum lumen and the biliary tract;
10. Then, we pass a self-expandable covered stent, size of variable size according to the need;
11. Should leave four combined-modality therapy stents in the duodenal lumen, to avoid migration as possible;
12. At the end, we infect contrast with a CPRE occlusion balloon to verify the waterproofing of the stent.

Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is still the most preferred method in Indonesia for patients with malignant obstructive jaundice. The role of therapeutic intervention endoscopic ultrasound (EUS) is still debatable regarding cost, availability, and hospital investment. Methods: Therapeutic intervention EUS cases were reviewed from our EUS hospital database within 2 years period. The EUS equipment was an Olympus JF UCT 180 EUS scope which was connected to an Aloka IPF-1701C ultrasound machine (Tokyo, Japan). Results: Of six patients who underwent therapeutic intervention EUS procedures, a 67-year-old male was referred with biliary obstruction due to duodenal malignancy with previous history of Billroth II operation. The papilla is placed at the duodenal bulb. Previous ERCP using the forward viewing scope was failed to attempt cannulation because of altered papilla due to advanced tumor. EUS-guided biliary drainage was then performed without any difficulty and a lumen-apposing metal stent (Hanaro stent) is placed from the duodenal bulb wall to the common bile duct. During follow-up, there was cholangitis complication which can be managed by antibiotic treatment. The bilirubin level went down within few days. Conclusion: EUS-guided biliary drainage case example has shown a high impact in gastroenterology practice in Indonesia which represents the biggest Southeast Asian country. However, the need of training curriculum has to be considered despite the cost and hospital investment.

We present the drainage of the biliary tract in a 75-year-old patient with a papillary tumor. In her, it was impossible to perform endoscopic retrograde cholangiopancreatography (ERCP). Steps are as given below:

1. After trying to perform ERCP and cannot do it, we change the duodenoscope by a Fujinon linear endosonograph;
2. We evaluate the dilated biliary track and from the gastric antrum. We achieve punction the biliary track. The puncture is made with a Boston scientific needle 19-gauge;
3. Then, bilis is sucked and we inject a medium of contrast, to see anatomy;
4. Once the anatomy is checked, a hydrophilic guide of 0.035 mm was passed, with special handling directed to the duodenum;
5. At this time, we remove the lineal endosonograph and pass a duodenoscope of side vision. We grasp the hydrophilic guide with a snare and introduce it into the duodenoscope, passing through it a papilotome. Then, we perform a conventional ERCP with a self-expandable stent.

Evolution was satisfactory

A 55-year-old male patient presented with complaints of increasing jaundice with itching and low-grade fever. He had undergone right extended hepatectomy 6 months back for right lobe hepatocellular carcinoma. Investigations revealed a total count of 9200/cumm, a bilirubin level of 18.6 mg/dl, and serum glutamic-pyruvic transaminase of 72 IU/L. Ultrasonography done revealed multiple para-aortic nodes and dilated left duct and intrahepatic biliary radical (IHBR). Computed tomography (CT) scan revealed multiple nodes at the area of the original confluence pressing of the left duct with dilatation of the left duct and IHBR. CT revealed a bowel loop near the hilum suggestive of end of jejunum to side of the left duct anastomosis with a tight narrowing at that level. We planned to palliate the patient with an endoscopic ultrasound (EUS)-guided hepaticogastrostomy. EUS was attempted with an intent to do a left duct drainage into the stomach with a Giobor stent. B3 radicle was carefully selected and puncture was made with a 19-gauge needle. The contrast did not go beyond the hilum. A Terumo guide wire was introduced and luckily the wire went into the distal common bile duct. This suggested that the hepaticojejunostomy was done end to side to the hilum. Hence, we now got the wire out of the papilla and performed a rendezvous procedure draining the left duct in the duodenum as this is much safer procedure than a hepaticogastrostomy. The patient was kept nil orally for 6 h and then on liquids for 24 h and diet started.

Case Report: A 47-year-old gentleman was referred from GP clinic for postprandial abdominal bloating for 2 months associated with early satiety. There was no weight loss/dysphagia/odynophagia/nausea/vomiting. His medical history includes hypertension and dyslipidemia, for which he is on treatment. Physical examination was unremarkable. Esophagogastroduodenoscopy (OGD) followed by endoscopic ultrasound (EUS) were performed. OGD showed rounded esophageal subepithelial “nodules” located at 27–30 from incisors. These nodules seemed to move with peristalsis. The overlying esophagus mucosa appeared normal. Subsequently, EUS was done which confirmed that these nodules were in fact the result of external compression by the thoracic vertebrae, hence the OGD findings. Discussion: Subepithelial lesions (SELs) are usually discovered incidentally in the esophagus during routine upper gastrointestinal endoscopy. SELs can be either intramural (e.g., leiomyoma, gastrointestinal stromal tumor, lipoma, etc.) or extramural (aneurysm, lymph node, spine, etc.). EUS is useful in the diagnosis of esophageal SELs because of good sensitivity as well as specificity. Thoracic spine indentation of the esophagus is rarely symptomatic but may cause symptoms such as dysphagia or even erosion in severe cases.

Background: Perianal fistulas are a frequent cause of morbidity and occur due to cryptoglandular infection, Crohn’s disease, radiotherapy, and malignancy. Perianal fistula occurring as a complication of anal canal surgery is an infrequent cause. We report endoscopic ultrasound (EUS)-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection. Case Report: A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He was operated for imperforate anus at birth and developed anal stricture requiring repeated bougienage dilation till 4 years of age. After anal dilatation, he had intermittent passing of urine through anal opening and was diagnosed to have ano-urethral fistula. He underwent multiple surgeries (three times) for the repair of fistula till the age of 16 and remained well till the age of 33. He presented with recurrent urinary tract infection. Radial EUS showed a tortuous fistula in anal canal communicating with prostatic urethra which was visualized due to air bubbles. A linear EUS-guided glue injection was planned. The patient was catheterized. Glue was injected into the middle part of fistula with successful closure. While injecting glue, the Foley’s catheter was rotated to avoid sticking of glue to the catheter. The patient is symptom-free on follow-up for 1 year. To conclude, we can say that EUS-guided cyanoacrylate glue can be safely attempted to treat postsurgical ano-urethal fistula.

A 56-year-old gentleman presented with complaints of hematemesis and melena. He had no postural symptoms. He had a history of acute pancreatitis, for which he was admitted in our unit 2 months ago. He underwent an upper gastrointestinal (GI) scopy which showed patchy elevated and erythematous duodenal mucosa in the first part. No blood was noted within the stomach. A computed tomographic angiogram was done with the clinical suspicion of pseudoaneurysm, this showed walled-off pancreatic necrosis (WOPN) around the head of pancreas and the gastroduodenal artery coursing close to WOPN. No obvious aneurysmal dilatation was noted. While in hospital, he had another large bout of hematemesis after a week (approximately 500 ml), at which a repeat upper GI scopy was done which showed a small opening in the first part of duodenum discharging purulent material. An endoscopic ultrasound (EUS) was done for assessment of the vessels. EUS showed a vessel (gastroduodenal artery) within WOPN with an aneurysmal dilatation. Turbulent flow noted within the aneurysm (Yin Yang sign was seen). The patient subsequently underwent a digital subtraction angiography which revealed aneurysm in the gastroduodenal artery, for which coil embolization was done. The case highlights the utility of EUS in identifying vascular abnormalities.

Background: Bleeding due to a pseudoaneurysm is a life-threatening condition in chronic pancreatitis. Pseudoaneurysm is usually obliterated by digital subtraction angiography (DSA) and embolization. We report a rare case of recurrent pesudoaneurysmal bleed from the left inferior phrenic artery which was obliterated by endoscopic ultrasound (EUS)-guided N-butyl 2-cyanoacrylate glue injection, after failed DSA. Case Report: A 43-year male, chronic alcoholic and smoker, was diagnosed as a case of alcoholic chronic pancreatitis based on imaging. He presented with massive upper gastrointestinal bleed (UGIB) with shock to emergency. His gastroduodenoscopy and colonoscopy were normal. Computed tomographic angiography revealed contrast extravasation from left inferior phrenic artery, but DSA was not technically possible. He had two more episodes of UGIB in 3 months’ duration. Percutaneous thrombin (500 units) was injected with subsequent thrombosed pseudoaneurysm on Doppler study. However, he had another episode of bleeding and an EUS examination showed large revascularized pseudoaneurysm (3.6 cm × 2.3 cm). It was obliterated with EUS-guided 3 mL N-butyl 2-cyanoacrylate glue (1:1 dilution with lipoidal) injection with 22-gauge EUS-guided fine needle aspiration needle. In the same session, two more glue injections completely obliterated the pseudoaneurysm. Conclusions: Left inferior phrenic artery pseudoaneurysm is a very rare cause of UGIB in chronic pancreatitis. Due to technical difficulty during DSA, it could be managed with EUS-guided N-butyl 2-cyanoacrylate glue injection.

A 55–year-old male presented with recurrent upper gastrointestinal (GI) bleed; he is diagnosed as chronic liver disease, portal hypertension, hepatocellular carcinoma with portal vein tumor thrombus. On upper GI endoscopy, there were large IGV1 fundal varices – glue injection done twice recently; however, he continues to have recurrent episode hematemesis requiring blood transfusion. Endoscopic ultrasound was done and hemostasis achieved.

Background: In spite of the modest size of the ovaries, they are frequently the site of many physiological and pathological lesions. Ovarian fine needle aspiration cytology (FNAC) can help in differentiation of ovarian lesions. It is usually performed under ultrasonography or computed tomography (CT) guidance. We report a case of endoscopic ultrasound (EUS)-guided FNAC of ovarian mass from the rectum. Case Report: A 65-year-old hypertensive woman with a history of bypass surgery presented with abdominal distension for 1 month and weight loss. CT (abdomen) revealed gastric wall thickening, omental thickening, ascites, and left adnexal mass measuring 4.5 cm × 5 cm. Carcinoembryonic antigen and cancer antigen 125 were elevated. Gastroscopy was normal. Being a poor surgical candidate, EUS was planned to define the primary diagnosis. EUS from stomach revealed hyperechoic omental deposits whose FNAC was performed with a 22-gauge needle. EUS performed from upper rectum revealed hypoechoic ovarian mass. FNAC was performed with the 22-gauge needle. Ovarian and omental FNAC (H and E stain) revealed scattered atypical epithelial cells. Immunohistochemistry confirmed the diagnosis of primary mucinous ovarian cancer. The patient underwent neoadjuvant chemotherapy. Discussion: We present a novel technique of EUS-guided FNAC of ovarian mass from rectum. After reviewing the literature, this appears to be the first case where EUS-guided FNAC was utilized from rectum for diagnosis of ovarian mass Conclusions: This case demonstrates the potential use of EUS in ovarian lesions. Adequate samples for immunohistochemistry are possible with EUS-FNA. Imaging is better because of proximity to ovary and use of high frequency probes. Further studies are required to explore the use of EUS in adnexal masses.

A 57-year-old male underwent ultrasound abdomen for nonspecific pain. The ultrasound abdomen showed a lesion in the body of pancreas. The patient was referred for endoscopic ultrasound (EUS) evaluation of a pancreatic lesion. EUS showed a 3.3 cm solid lesion in the body of pancreas with alternating thin hypoechoic and thick hyperechoic irregular layers giving it an appearance-like sulci and gyri of the brain. EUS-guided fine needle aspiration was done; the aspirate was positive for numerous hydatid scolices, thus confirming the diagnosis of pancreatic hydatid disease.

A 52-year-old male presented with nonspecific upper abdominal pain. His ultrasound abdomen revealed gallbladder wall thickening. A contrast (dynamic) computed tomography (CT) abdomen was suggestive of carcinoma gallbladder. He was planned for surgery and a positron emission tomography (PET) CT was done; it showed PET avid lesion of gallbladder small portocaval node with fluorodeoxyglucose uptake. The patient was referred to endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) from lymph node. EUS-guided FNA from portocaval node was suggestive of reactive change. In addition, EUS showed several very small (<5 mm) lesions in the liver parenchyma which were suspicious of metastasis. These lesions were not visible in USG, contrast CT, and PET CT. EUS-guided FNA was taken from these lesions, FNA confirmed metastasis, and a futile surgery could be avoided.

Background: Hepatic hydatid cyst rupture into the bile ducts (intrabiliary rupture) is the most common and serious complication of hepatic hydatid disease, occurring in 2%–42% of cases. Intrabiliary rupture (IBR) can be diagnosed by ultrasonography, computerized tomography, or magnetic resonance imaging. Methods: Transabdominal ultrasonography showed a 3.2 cm × 3.4 cm cyst in the right lobe of the liver, dilatation of the biliary system up to the lower end of the common bile duct (CBD), and biliary sludge in the gallbladder. Linear EUS was performed before endoscopic retrograde cholangiopancreatography (ERCP) to know the etiology of cholangitis. Results: Linear EUS from stomach revealed multiple curvilinear, leaflet-shaped, rounded, and irregular structures within dilated CBD and common hepatic duct. These structures were hyperechoic, multilayered, with intervening anechoic areas without acoustic shadowing indicating membranous structures folded many times. The structures were floating inside the CBD suggestive of hydatid membranes. Cholangiogram revealed a dilated CBD with multiple irregular filling defects formed by the hydatid membranes. ERCP with biliary sphincterotomy and balloon sweeping resulted in CBD clearance with expulsion of the multiple bile stained and whitish hydatid membranes. There was a significant improvement in clinical condition after ERCP. Follow-up USG after 2 weeks revealed normal CBD with decreased size of liver cyst. Conclusions: EUS by demonstrating the presence of mobile hydatid membranes or cyst-like material may be useful when other imaging modalities are inconclusive or unavailable in IBR. ERCP is both diagnostic and therapeutic in IBR, with removal of hydatid membranes relieving jaundice and cholangitis.

We have come across four cases presented to us with a history of abdominal pain, jaundice, cholangitis, and acute pancreatitis. On investigating, we found that all had distal common bile duct (CBD) polyps or polypoidal lesions causing these symptoms. All were subjected to endoscopic ultrasound and then endoscopic retrograde cholangiopancreatography. Papillotomy was done, the polyps brought out of the CBD with a balloon or a basket and then snared off, and CBD and PD stents were placed. The histopathology showed adenomatous polyps with low-grade dysplasia in three cases and adenofibroma/hamartomatous polyp in one. One patient was found to have underlying malignancy after 2 months. Conclusion: Distal CBD polyps though not a common occurrence are seen in clinical practice and can cause abdominal pain, jaundice, cholangitis, and acute pancreatitis.

An 18-year-old female presented with recurrent pain abdomen of 1-month duration. Laboratory investigation suggested raised serum amylase and lipase with mildly abnormal liver functions. Ultrasonography abdomen showed mildly dilated common bile duct (CBD) with normal gall bladder and pancreas. Endoscopic ultrasound, with a radial echoendoscope, showed mildly dilated CBD having a long linear echogenic structure having tram track appearance extending along its entire extent (similar to a plastic biliary stent). The pancreas appeared normal. At endoscopic retrograde cholangiopancreatography, the papilla was normal and cholangiogram on selective biliary cannulation confirmed the presence of long linear filling defect in entire length. Biliary sphincterotomy and balloon sweep showed an intact dead Ascaris worm. Since then, the patient has no recurrence of pain.

An 18-year-old male presented 3 months after acute severe pancreatitis with ascites and large pancreatic fluid collection (PFC). He had no history of alcohol, drug abuse, or allergies. Blood count showed peripheral eosinophilia (44%) with high absolute eosinophilic count (1800 cells/mm³). Percutaneous drainage (PCD) was done for significant pancreatic ascites. Ascitic fluid analysis showed low-gradient ascites with eosinophilic predominance (800 cells/mm³ with 80% eosinophils) and raised fluid amylase levels (1331 U/L). Due to persistent pain and PFC, he underwent EUS-guided cystogastric drainage of walled-off necrosis (WON) with Nagi stent. WON fluid analysis had high amylase levels (49,500 U/l) with normal eosinophil count. He continued to have high volume drainage in PCD. Later, he required endoscopic necrosectomy for infected necrosis during which a cyst wall biopsy was also taken. Histology confirmed eosinophilic pancreatitis. After resolution of infected WON, he was treated with oral prednisolone (40 mg/day) with rapid recovery.

A 36-year-old male presented with obstructive jaundice and acute pancreatitis. Both imaging and an upper gastrointestinal endoscopy revealed malignant duodenal obstruction involving first and second parts. The patient was managed conservatively for acute pancreatitis. Endoscopic retrograde cholangiopancreatography was not possible in view of duodenal pathology. Endoscopic ultrasound (EUS)-guided hepaticogastrostomy was planned. Walled-off pancreatic necrosis as well as ascites was noted on EUS. Hepatic duct access was gained; a guidewire placement with track dilation using 6 Fr cystotome (Endoflex) was performed. A Giobor stent (Taewoong Medical, 8 mm × 10 cm long) was placed between the liver and stomach; immediate migration of the stent was noted resulting in to the impaction of the proximal end in to the gastric wall. Retrieval attempts made over the in-stent placement of a 7 Fr. Double pigtail plastic stent was unsuccessful. Plastic stent was removed after stent intubation carried out over a guidewire placed through the side hole. Retrieval using a Hurricane balloon (8 mm, Boston Scientific) was also unsuccessful. Eventually, successful biliary drainage was performed using both bare (10 mm × 60 mm, Taewoong Medical) biliary metal stent placement through the Giobor stent. An enteral stent (WallFlex Duodenal, Boston Scientific) was placed for the duodenal obstruction.

A 40-year-old man, previously diagnosed alcoholic chronic pancreatitis, presented with abdominal pain and recurrent vomiting with significant weight loss for 1 month. Imaging confirmed dilated pancreatic duct with small pseudocyst in the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) was not feasible due to pyloroduodenal narrowing causing gastric outlet obstruction. Endoscopic ultrasound (EUS) confirmed small pseudocyst in the pancreatic head with dilated pancreatic duct. EUS-guided trans-gastric pancreatic duct drainage was done, and a 7 Fr single pigtail stent was placed, with the distal end across the papilla and proximal half in the stomach. His symptoms gradually improved with relief in pain and vomiting, associated with weight gain. Imaging confirmed resolution of pseudocyst. Repeat ERCP, 2 months later, confirmed significant reduction of the pyloroduodenal narrowing. A transpapillary pancreatic duct stent was placed after removal of previously placed EUS-guided pancreatic duct stent.

Background: Endoscopic ultrasound (EUS) has been widely used as the modality for drainage of pancreatic pseudocyst or walled-off necrosis. We described a case of EUS-guided drainage complicated with bleeding and successfully stopped by lumen-apposing metal stent (LAMS) and balloon tamponade. Case Report: A 49-year-old man presented with acute pancreatitis in April 2015. Follow-up imaging showed a persistent 12 cm pancreatic pseudocyst. EUS-guided drainage of the pseudocyst was performed but complicated with bleeding. LAMS and balloon tamponade were used for drainage and hemostasis. The pseudocyst was successfully drained by EUS-guided LAMS drainage. Reassessment computed tomography scan showed pseudocyst significantly reduced in size. Conclusion: EUS-guided drainage with LAMS is an effective means of pancreatic pseudocyst drainage. LAMS and balloon tamponade can be used for hemostasis in case of bleeding after EUS-guided drainage.

Background: Endoscopic ultrasound (EUS)-guided biliary drainages are increasingly performed in patients with failed endoscopic retrograde cholangiopancreatography. Common approaches for transmural drainage include choledochoduodenostomy and hepaticogastrostomy (HGS). In this video, we describe three patients with difficult EUS-biliogastric anastomosis and advanced interventions through the established anastomosis. Case Report: Case 1 describes a case in which a choledochogastric anastomosis was performed. A 74-year-old female presented with upper gastrointestinal bleeding with failed endoscopic hemostasis requiring surgical plication of the bleeder, closure of the pylorus and gastrojejunostomy due to a locally advanced pancreatic cancer. She then developed biliary obstruction. A EUS-guided choledochogastrostomy was then performed with a forward-viewing echoendoscope. Case 2 describes a EUS-guided salvage of a misdeployed HGS stent. EUS-guided HGS was performed in a patient with unresectable gastric cancer with pyloric obstruction. During deployment, the proximal end of the stent was deployed in to the peritoneal cavity with loss of guidewire. EUS-guided HGS was then performed to the misdeployed stent. Case 3 describes a patient with 2-staged endoscopic recanalization of a stenosed surgical hepaticojejunostomy for benign distal biliary stricture via a EUS-guided HGS. In the first stage, a EUS-guided HGS was performed through the left intrahepatic duct. The video describes the second stage of the procedure where endoscopic recanalization of the surgical hepaticojejunostomy was performed a few months later. Conclusion: Advanced biliogastric anastomoses and interventions were feasible and successfully avoided surgical interventions in these patients.

A 56-year-old male patient presented with complaints of severe abdominal pain in the right paraumbilical region and epigastrium with fever and vomiting for 5 days. He had a history of acute pancreatitis related to alcohol before 6 weeks and had been admitted to the hospital elsewhere for 12 days. Investigations revealed a high total count of 18,700/cumm and clinically had tenderness and guarding in the right upper and paraumbilical region with fever. Computed tomography scan revealed a collection with some necrosis in the area of the C loop of the duodenum with edematous duodenal mucosa. Pancreatic duct (PD) was mildly dilated and common bile duct was prominent. Gallbladder was distended with sludge in it. We planned to assess the collection with endoscopic ultrasound and decide whether it is feasible for internal drainage or to call the surgeon. Highlights of this procedure – The puncture was possible only with a long loop position of the scope. A 19-gauge flex needle was used. He challenge was how much to dilate the cystoduodenostomy. We chose to dilate with a hurricane balloon up to 8 mm and then placed two 7 Fr double pigtail stents. We got an excellent drainage of frank pus and the pus was sent for culture and sensitivity. On follow-up, he was on intravenous antibiotics and discharged after 48 h. An ultrasound at 48 h revealed 3 ml collection. We plan to administer antibiotics for 10 days and review with magnetic resonance cholangiopancreatography at 3 weeks to see for leak and PD-stenting SOS.

Background: Hepatic artery pseudoaneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct, or portal vein. Essentially, all pseudoaneurysms, whether symptomatic or not symptomatic, require early treatment to prevent lethal complications. Case Report: A 20-year-old male presented with abdomen pain in the right upper quadrant for 2 months. He had undergone ultrasound-guided aspiration of liver abscess 2 months ago. Computed tomography angiography of the abdomen showed a saccular pseudoaneurysm arising from the proximal part of hepatic artery. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of stent. The patient chose endoscopic ultrasound (EUS)-guided coil embolization. Packing with one coil of 10 mm and five coils of 6 mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later, EUS assessment showed the injected coils were collected into the most distal part of the aneurysm, but the flow into a smaller cavity continued with high velocity. During the second attempt, four coils of 10 mm size were deployed. Postcoiling, EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later, follow-up color Doppler abdomen showed no flow in the pseudoaneurysm.

Pancreatic pseudoaneurysm converted from a pancreatic pseudocyst is rare but may cause fatal hemorrhage. We report a 42-year-old man with pancreatic pseudocyst in the pancreatic tail which was found by computed tomography in other hospital was referred to our hospital for endoscopic ultrasound(EUS) guided drainage. However, examination by EUS of the pancreas identified a pseudoaneurysm at the level of the pancreatic body, which was represented by a well-defined, 3.5-cm maximal diameter echogenic lesion containing an anechoic area of 1.5 cm with flow detected by Doppler. We immediately terminated the procedure and the patient remained hemodynamically stable. A pseudoaneurysm in the pancreatic tail was detected on contrast-enhanced abdominal computed tomography (CT), which communicated with the splenic artery. A coil embolization of the splenic artery was successfully performed with a favorable outcome. Follow-up contrast-enhanced abdominal CT revealed that the pseudoaneurysm was no longer present. Timely and accurate diagnosis has a great influence on the prognosis of patients with pancreatic pseudoaneurysm. With development of EUS, We do believe that EUS is being an alternative option for the diagnosis of pancreatic pseudoaneurysm.

Case Report: A 25-year-old female with no significant medical history was admitted to National University Hospital, Singapore 2 months ago with abdominal pain, vomiting, fever, and melena for 2 weeks. Inflammatory markers were raised with computed tomography (CT) showing diffuse mucosa thickening at terminal ileum, cecum, and ascending colon with multiple lymphadenopathy. Biopsy of the colon showed acute on chronic colitis with granulomas, acid-fast bacilli (AFB) negative (polymerase chain reaction [PCR] and culture). The patient was treated as Crohn’s disease with prednisolone and azathioprine. She came to our hospital 2 months later with fever and loss of appetite. The patient has defaulted treatment for a week as well. Repeat CT and colonoscopy showed similar findings as before. Endoscopic ultrasound (EUS) and fine needle aspiration (FNA) of peripancreatic lymph node were performed. Lymhoid tissue with necrosis and occasional acid fas bacilli were seen. Lymph node culture and PCR for AFB were negative. The patient was treated for tuberculous enteritis and recovered well following completion of therapy. Discussion: Diagnosis of tuberculosis (TB) enteritis can be difficult to establish. The disease may mimic other conditions such as Crohn’s disease and lymphoma. EUS-guided FNA of the lymph nodes has been shown to be helpful in cases where repeated tests for TB were negative.

A 32-year-old female presented with jaundice, fever, and weight loss for 3 months in December 2015. Ultrasound abdomen showed pancreatic head mass with dilated bile duct. Magnetic resonance cholangiopancreatography showed a pancreatic head mass with normal body and tail of pancreas with dilated bile duct. Endoscopic ultrasound-guided fine needle aspiration from pancreatic head mass showed granuloma. The patient was started with antituberculosis treatment (ATT) and underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting. The patient responded to therapy and continued with ATT for 1 year with bile duct stent in situ. The patient now presented with pancreatic type pain and onset of diabetes. Computed tomography scan showed atrophic pancreas with dilated pancreatic duct in tail. EUS showed five features suggestive of chronic pancreatitis. Blood sugar was elevated suggesting diabetes. The patient was started with oral hypoglycemic agent for diabetes. ERCP was carried out and stent removed. ATT was stopped and pancreatic enzymes were started for pain relief. This case demonstrated that pancreatic tuberculosis may lead to development of chronic pancreatitis in a short period (1 year in this case).

Case 1: A 34-year-old female had breast surgery followed by chemotherapy in 2006. She had local axillary recurrence after 2 year after surgery, for which he received treatment. She had bone lytic lesion in 2011 for which she received radiotherapy and was kept on hormonal therapy. She was doing well. A positron emission tomography scan in 206 showed posterior pericardial lesion measuring 3.2 cm × 1.6 cm. An endoscopic ultrasound-guided fine needle aspiration (EUS FNA) was done from pericardial lesion which was positive for malignancy. Case 2: A 52-year-old male with hepatitis B virus-related compensated liver cirrhosis (Child–Pugh–Turcotte - 6, model for end-stage liver disease - 14) with multicenter hepatocellular carcinoma (HCC) status posttransarterial chemoembolization, planned for living donor liver transplantation after complete workup. He had an isolated 9.5 mm paracaval lymph node at large axis on recent dynamic computed tomography and was referred for EUS FNA as a routine protocol for HCC. We did EUS-FNA with 25-gauge needle transaortic and transvenous, one pass was taken from the lymph node which was positive for malignancy, and LT was deferred.

Background: Endoscopic ultrasound (EUS) allows bile duct drainage in case of endoscopic retrograde cholangiopancreatography (ERCP) failure or inaccessible papilla, during the same anesthetic time, as an alternative to delayed radiological drainage. Our study aims were to review indications, techniques, and early complications (<7 days) of biliary drainage by EUS as a second-line treatment after ERCP failure, including inaccessible papilla and failed ERCP. Methods: This was a retrospective evaluation carried out between 2002 and 2016. Results: Out of >8400 ERCPs performed during this period, 31 patients (68 years range 14–92) were included. 66% (19/29) had failed bile duct drainage due to neoplastic infiltration and the others had inaccessible papilla: roux-en-Y limb (3/10), duodenal stenosis (6/10), or stent (1/10). 65% were drained transgastrically and 35% through the bulb. Drainage was achieved by placing a transmural stent in 79% of cases, “rendezvous” in 14%, and anterograde access in 7%. Two gallbladder drainages were performed in inoperable patients with acute cholecystitis. Average procedural time was 68 min. There were four early complications, including pneumoperitoneum before CO₂ use, three stent migrations, or malposition, all of which treated endoscopically. Conclusions: EUS-guided biliary and vesicular drainage can be safely performed even in low rates of ERCP failures.

A 70-year-old woman presented with features of extrahepatic biliary obstruction. Evaluation was suggestive of a locally advanced carcinoma head of the pancreas. Endoscopic retrograde cholangiopancreatography was attempted for relief of cholestatic symptoms; however, the lumen of duodenum in the junction between its first and second part was narrowed. This hindered the passage of a side viewing endoscope. Standard forward viewing scope could be passed across and it showed a normal papilla. Endoscopic ultrasound-guided access of the bile duct was planned. The dilated intrahepatic biliary radicle was punctured from the stomach with a 19-gauge needle (Expect – Boston Scientific) and contrast injected. A 0.035 inch guidewire (Visiglide-Olympus Corp., Japan) was then negotiated across the papilla. Over the wire, dilatation of the stricture and the hepaticogastrostomy access point was done using a 4 mm biliary balloon (Hurricane Rx – Boston Scientific). Following this, a fully covered self-expandable metallic stents (WallFlex – Boston Scientific) was placed across the papilla. However, postdeployment, we noted that the proximal flange of the stent had not opened fully and was partly within the stricture segment. OASIS (10 Fr) (Cook Medical) was inserted over the wire inside the bile duct. The guiding catheter was removed and a forceps was inserted through the OASIS, a forceps was inserted. Using the forceps, gentle traction was deployed to pull the stent proximally. The technique illustrates risk of distal deployment of fully covered self-expandable metallic stents during antegrade stenting and the use of OASIS to pass a forceps for pulling the stent proximally.

Background: Acute portal vein thrombosis is an uncommon and insidious disease that is potentially lethal due to delay in diagnosis and therapy. There are no uniform protocols for the effective treatment of acute portal vein thrombosis. Case Report: An 18-year-old female presented with intractable upper abdominal pain and vomiting. Abdominal ultrasound, computed tomography scan, and magnetic resonance image showed extensive thrombosis of portal venous system without bowel infarction. A diagnosis of acute portal vein thrombosis was made, and she was started on anticoagulants. The intractable pain persisted and endoscopic ultrasound (EUS)-guided thrombolysis was planned. A window of patent superior mesenteric vein (SMV) was selected for EUS-guided puncture. The puncture was made through the pancreas into SMV with a 22-gauze EUS-guided fine needle aspiration needle. A 0.018 guidewire was placed into a tributary of SMV. A tapered tip cannula was advanced over the wire, and cannula was positioned in the vein. The cannula was routed through the nose and a syringe pump was fitted for infusion of thrombolytic agent. Continuous catheter-guided thrombolytic therapy was started with streptokinase at a dose of 30,000 IU/h with systemic anticoagulation with low molecular weight heparin. Her prothrombotic workup suggested deficiency of protein C and protein S. The patient was discharged on the 7^th day with a satisfactory clinical and radiological response. A follow-up after 3 weeks showed flow in splenic and portal vein. Conclusion: EUS-guided continuous catheter thrombolysis may be tried in life-threatening acute portal vein thrombosis.

Background: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) could be used as an effective alternative treatment for peripancreatic tumor. Herein, we reported a case of adrenal adenoma which was treated by EUS-RFA. Case Report: A 38-year-old woman presented with “moon face,” “buffalo hump,” and weight gain of 9 kg in 12 months. Initial contrast-enhanced abdominal computed tomography showed a 2.8 cm left adrenal mass, and the patient was diagnosed with Cushing’s syndrome due to left adrenal adenoma. She refused surgical treatment but agreed to undergo EUS-RFA. A 19-gauge endoscopic RFA electrode and radiofrequency generator were used for the procedure. The length of the exposed tip of the RFA electrode was 10 mm. After insertion of the RFA electrode into the mass, the radiofrequency generator was activated to deliver 50 W ablation power for 10 s. Depending on tumor size, the procedure was repeated to sufficiently cover the tumor. Therefore, EUS-RFA was performed successfully. There were no adverse events after EUS-RFA. Conclusions: EUS-RFA could be a technically feasible and safe modality for patients who refuse surgical treatment.

Background: Endoscopic ultrasound (EUS)-guided vascular therapy is evolving. Herein, we report a case of recurrent gastrointestinal bleed which was incriminated to gastric varix, but EUS picked up 3 cm splenic artery pseudoaneurysm which was treated by EUS-guided coil and glue. Case Report: A 33-year-old male, chronic alcoholic, presented with hematemesis in August 2015, for which three units of blood were transfused and upper gastrointestinal (UGI) showed esophageal varices with gastric varix, for which endoscopic sclerotherapy and glue injection were done, respectively. The patient remained asymptomatic for the next 18 months, when in January 2017, he presented with melena over 1 month requiring 10 units of blood transfusion. Patient underwent repeat UGI with endoscopic sclerotherapy and glue injection for esophageal and gastric varix. Ultrasound showed splenic vein thrombosis with collaterals around the splenic hilum. After 1 month in February 2017, he again had hematemesis and melena, for which after resuscitation, he was referred to SGPGI. The patient was diagnosed as having splenic vein thrombosis with gastric varix. Since patient had undergone multiple session of glue injection, he was planned for EUS-guided therapy of gastric varix. However, on EUS, a large 3 cm splenic artery pseudoaneurysm was picked up which was missed by prior imaging. Pseudoaneurysm was confirmed on computed tomography (CT) angiogram. The patient underwent endoscopic glue therapy for residual gastric varix and EUS guided-coil and glue in splenic artery. Obliteration after EUS therapy was confirmed by repeat EUS and CT angiogram after 2 weeks which showed no splenic artery aneurysm and patient had no symptoms.

A 76-years-old man who underwent pylorus-preserving pancreaticoduodenectomy for lower cholangiocarcinoma developed peritonitis with intra-abdominal abscess from anastomotic leakage. We have done a reoperation for surgical drainage and jejunostomy for intestinal decompression. After operation, pancreatic leakage from anastomosis of pancreatico-jejunum was detected using contrast medium from jejunostomy. We tried percutaneous drainage for abscess several times but could not treat pancreatic leakage completely over 6 months hospitalization. The pancreatic duct stenting from the intestine by balloon endoscopy was impossible because of adhesion. We tried antegrade stenting using endoscopic ultrasound-guided pancreatic drainage (EUS-PD). In EUS findings, we could identify main pancreatic duct with a diameter of 1.3 mm. It is too thin to insert the needle for EUS-PD. Therefore, we punctured it with a 22-gauge needle and succeeded pancreatography. Then, we inserted 0.018 inch guidewire, and it reached into the duct of pancreatic head. After expanding the puncture site by ultra-tapered dilator and standard dilation catheter step-wisely, the guidewire was exchanged to 0.025 inch hard-type guidewire. We placed a new 7 Fr plastic stent smoothly across the pancreatic duct (Through Pass Type IT, Gadelius Medical, Tokyo, Japan); the distal part was in the intestine, and the proximal part (pigtail) was in the gastric lumen. Pancreatic leakage was improved and patient was discharged. EUS-PD with newly developed tube stent may be considered as an effective therapy in selected patients with a pancreatic leakage after pancreatectomy.

A 60-year-old woman presented with a history of T4N3b carcinoma of stomach with subtotal gastrectomy and roux-en-Y reconstruction performed. Adjuvant chemoradiation was given. She developed intestinal obstruction 1 year later with palliative colectomy performed. This time, she presented with repeated vomiting and abdominal pain with urgent computed tomography (CT) showing diffuse small bowel, biliary duct, and pancreatic duct with suspected recurrence at anastomosis. Esophagogastroduodenoscopy with stenting to efferent limb was performed. Subsequently, there was progressive worsening of liver function test. Repeated CT scan showed grossly dilated afferent limb, biliary duct, and pancreatic duct. Endoscopic ultrasound-guided drainage of the afferent limb was performed with lumen apposing metal stent. Liver function test almost normalized after the procedure and the patient was discharged afterward.