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Table of Contents
January-February 2022
Volume 11 | Issue 1
Page Nos. 1-87
Online since Monday, February 21, 2022
Accessed 26,008 times.
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EDITORIAL
Photoacoustic endoscopy and EUS: Shaking the future of multimodal endoscopy
p. 1
Kai Zhang, Jianjun Qiu, Fan Yang, Jing Wang, Xinyue Zhao, Zhigang Wei, Nan Ge, Yunliang Chen, Siyu Sun
DOI
:10.4103/EUS-D-22-00011
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REVIEW ARTICLES
EUS-guided
versus
percutaneous transhepatic cholangiography biliary drainage for obstructed distal malignant biliary strictures in patients who have failed endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis
p. 4
Umar Hayat, Caitlin Bakker, Ahmed Dirweesh, Mohammed Y Khan, Douglas G Adler, Hayrettin Okut, Noel Leul, Mohammad Bilal, Ali A Siddiqui
DOI
:10.4103/EUS-D-21-00009
PMID
:35083977
EUS-guided biliary drainage (EUS-BD) and percutaneous transhepatic cholangiography biliary drainage (PTC) are the two alternate methods for biliary decompression in cases where ERCP fails. We conducted a systematic review and meta-analysis of studies to compare the efficacy and safety of endoscopic and percutaneous biliary drainage for malignant biliary obstruction in patients with failed ERCP. A total of ten studies were included, fulfilling the inclusion criteria, including four retrospective studies and six randomized controlled trials. We compared the technical and clinical success rates and the acute, delayed, and total adverse events of EUS-BD with PTC. The odds ratios (ORs) and confidence intervals (CIs) were calculated. There was no difference between technical (OR: 0.47 [95% CI: 0.20–1.07];
P
= 0.27) and clinical (OR: 2.24 [95% CI: 1.10–4.55];
P
= 0.51) success rates between EUS-PD and PTC groups. Procedural adverse events (OR: 0.17 [95% CI: 0.09–0.31];
P
= 0.03) and total adverse events (OR: 0.09 [95% CI: 0.02–0.38];
P
< 0.01) were significantly different between the two groups; however, delayed adverse events were nonsignificantly different (OR: 0.73 [95% CI: 0.34–1.57];
P
= 0.97). This meta-analysis indicates that endoscopic biliary drainage (EUS-BD) is equally effective but safer in terms of acute and total adverse events than percutaneous transhepatic biliary drainage (PTC) for biliary decompression in patients with malignant biliary strictures who have failed an ERCP.
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Application of artificial intelligence for diagnosis of pancreatic ductal adenocarcinoma by EUS: A systematic review and meta-analysis
p. 17
Thaninee Prasoppokakorn, Thodsawit Tiyarattanachai, Roongruedee Chaiteerakij, Pakanat Decharatanachart, Parit Mekaroonkamol, Wiriyaporn Ridtitid, Pradermchai Kongkam, Rungsun Rerknimitr
DOI
:10.4103/EUS-D-20-00219
PMID
:34937308
EUS-guided tissue acquisition carries certain risks from unnecessary needle puncture in the low-likelihood lesions. Artificial intelligence (AI) system may enable us to resolve these limitations. We aimed to assess the performance of AI-assisted diagnosis of pancreatic ductal adenocarcinoma (PDAC) by off-line evaluating the EUS images from different modes. The databases PubMed, EMBASE, SCOPUS, ISI, IEEE, and Association for Computing Machinery were systematically searched for relevant studies. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic curve were estimated using R software. Of 369 publications, 8 studies with a total of 870 PDAC patients were included. The pooled sensitivity and specificity of AI-assisted EUS were 0.91 (95% confidence interval [CI], 0.87–0.93) and 0.90 (95% CI, 0.79–0.96), respectively, with DOR of 81.6 (95% CI, 32.2–207.3), for diagnosis of PDAC. The area under the curve was 0.923. AI-assisted B-mode EUS had pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.91, 0.90, 0.94, and 0.84, respectively; while AI-assisted contrast-enhanced EUS and AI-assisted EUS elastography had sensitivity, specificity, PPV, and NPV of 0.95, 0.95, 0.97, and 0.90; and 0.88, 0.83, 0.96 and 0.57, respectively. AI-assisted EUS has a high accuracy rate and may potentially enhance the performance of EUS by aiding the endosonographers to distinguish PDAC from other solid lesions. Validation of these findings in other independent cohorts and improvement of AI function as a real-time diagnosis to guide for tissue acquisition are warranted.
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TRAINING COURSE
Controversies in ERCP: Technical aspects
p. 27
Christoph F Dietrich, Noor L Bekkali, Sean Burmeister, Yi Dong, Simon M Everett, Michael Hocke, Andre Ignee, Wei On, Srisha Hebbar, Kofi Oppong, Siyu Sun, Christian Jenssen, Barbara Braden
DOI
:10.4103/EUS-D-21-00102
PMID
:34677144
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
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ORIGINAL ARTICLES
Hepaticogastrostomy
versus
choledochoduodenostomy: An international multicenter study on their long-term patency
p. 38
Amy Tyberg, Bertrand Napoleon, Carlos Robles-Medranda, Janak N Shah, Erwan Bories, Nikhil A Kumta, Andres Sanchez Yague, Enrique Vazquez-Sequeiros, Sundeep Lakhtakia, Abdul Hamid El Chafic, Shawn L Shah, Sohini Sameera, Augustine Tawadros, Jose Celso Ardengh, Prashant Kedia, Monica Gaidhane, Marc Giovannini, Michel Kahaleh
DOI
:10.4103/EUS-D-21-00006
PMID
:34494590
Background and Objectives:
EUS-guided biliary drainage (EUS-BD) offers minimally invasive decompression when conventional endoscopic retrograde cholangiopancreatography fails. Stents can be placed from the intrahepatic ducts into the stomach (hepaticogastrostomy [HG]) or from the extrahepatic bile duct into the small intestine (choledochoduodenostomy [CCD]). Long-term patency of these stents is unknown. In this study, we aim to compare long-term patency of CCD
versus
HG.
Methods:
Consecutive patients from 12 centers were included in a registry over 14 years. Demographics, procedure info, adverse events, and follow-up data were collected. Student's
t
-test, Chi–square, and logistic regression analyses were conducted. Only patients with at least 6-month follow-up or who died within 6-month postprocedure were included.
Results:
One-hundred and eighty-two patients were included (93% male; mean age: 70; HG
n
= 95, CCD
n
= 87). No significant difference in indication, diagnosis, dissection instrument, or stent type was seen between the two groups. Technical success was 92% in both groups. Clinical success was achieved in 75/87 (86%) in the HG group and 80/80 (100%) in the CCD group. A trend toward higher adverse events was seen in the CCD group. A total of 25 patients out of 87 needed stent revision in the HG group (success rate 71%), while eight out of 80 were revised in the CCD group (success rate 90%). Chi square shows CCD success higher than HG (90%
vs
. 71%,
P
= 0.010). After adjusting for diagnosis, jaundice or cholangitis presentation, instrument used for dissection, and gender, CCD was 4.5 times more likely than HG to achieve longer stent patency or manage obstruction (odds ratio 4.5; 95% 1.1548–17.6500,
P
= 0.0302).
Conclusion:
CCD is associated with superior long-term patency than HG but with a trend toward higher adverse events. This is particularly important in patients with increased survival. Additional studies are required before recommending a change in practice.
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Long-term outcomes of EUS-guided lauromacrogol ablation for the treatment of pancreatic cystic neoplasms: 5 years of experience
p. 44
Chen Du, Ningli Chai, Enqiang Linghu, Huikai Li, Xiuxue Feng, Bo Ning, Xiangdong Wang, Ping Tang
DOI
:10.4103/EUS-D-20-00231
PMID
:33473042
Background and Objectives:
We initially reported EUS-guided lauromacrogol ablation (EUS-LA) to treat pancreatic cystic neoplasms (PCNs); however, its long-term effectiveness remains unknown. This study was performed to further determine the effectiveness of EUS-LA in a larger population with a long-term follow-up based on 5 years of experience with EUS-LA.
Materials and Methods:
From April 2015 to April 2020, 279 patients suspected of having PCNs were prospectively enrolled, and seventy patients underwent EUS-guided ablation using lauromacrogol alone. Fifty-five patients underwent follow-up, 35 of whom had a follow-up duration of at least 12 months. The effectiveness of ablation was determined based on volume changes.
Results:
Among the fifty female and twenty male patients with an overall mean age of 50.3 years, cysts were located in the head/neck of the pancreas in 37 patients (52.9%) and in the body/tail of the pancreas in 33 patients (47.1%). The adverse events rate was 3.6% (3/84), with 14 patients undergoing a second ablation. Among the 55 patients who underwent follow-up, the median cystic volume sharply decreased from 11,494.0 mm
3
to 523.6 mm
3
(
P
< 0.001), and the mean diameter decreased from 32.0 mm to 11.0 mm (
P
< 0.001). Postoperative imaging showed complete resolution (CR) in 26 patients (47.3%) and partial resolution (PR) in 15 (27.3%) patients. CR was observed in 18 (51.4%), and PR was observed in 9 (25.7%) patients among the 35 patients followed for at least 12 months.
Conclusions:
EUS-LA was effective and safe for the treatment of PCNs with stable effectiveness based on at least 12 months of follow-up.
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Double pigtail stent placement as an adjunct to lumen-apposing metal stents for drainage of pancreatic fluid collections may not affect outcomes: A multicenter experience
p. 53
Steven P Shamah, Ara B Sahakian, Christopher G Chapman, James L Buxbaum, Thiruvengadam Muniraj, Harry A Aslanian, Edward Villa, Jaehoon Cho, Haider I Haider, Irving Waxman, Uzma D Siddiqui
DOI
:10.4103/EUS-D-21-00030
PMID
:35102901
Background and Objectives:
EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention.
Methods:
We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS.
Results:
There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates.
Conclusion:
This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.
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Lumen-apposing metal stents: How far are we from standardization? An Italian survey
p. 59
Carlo Fabbri, Chiara Coluccio, Cecilia Binda, Alessandro Fugazza, Andrea Anderloni, Ilaria Tarantino, i-EUS Group
DOI
:10.4103/EUS-D-21-00015
PMID
:34677143
Background and Objectives:
EUS-guided transluminal drainage has increasingly developed, especially after the era of lumen-apposing metal stent (LAMS): a fully covered, barbell-shaped, metal stent with anti-migratory properties allowing direct therapeutic interventions through a wide and short channel. The aim of this survey is to investigate the current management of patients undergoing LAMS placement nationwide.
Materials and Methods:
Forty-eight questions were submitted to Italian centers about expertise, peri- and intra-procedural aspects, budget/refund, and future perspectives. Statistical analyzer was SPSS®.
Results:
Thirty-six centers completed the survey. Indications for LAMS positioning are pancreatic fluid collection drainage (PFCD, 97.2%), biliary drainage (BD, 80.5%), gallbladder drainage (GBD, 75%), and gastroentero-anastomosis (GEA, 19.4%). A total of 77.7% of the endoscopists perform only on-label procedures and 22.2% both on-label and off-label. 38.8% attended a training preliminary course, 27.7% were just supported by an expert, 22.2% had both the opportunities, and 8.3% none of them. Management of antiplatelets and sedation protocol is very heterogeneous. Only 50% involves a multidisciplinary meeting and 30.5% has a specialized clinic for follow-up. Acid suppression is usually continued after PFCD. The type and timing of postprocedural imaging varies widely. 8.3% of the endoscopists work without fluoroscopy. Refund for LAMS is mostly not guaranteed. Main future growing indications appear to be BD, GBD, and GEA (69.4%, 55.5%, and 55.5%, respectively).
Conclusions:
This is the first survey assessing the state of the art on LAMS almost 10 years after their advent. There are currently wide variations in practice nationwide, which demonstrates a pressing need to define technical, qualitative, and peri-procedural requirements to carry out this procedure, toward a standardization.
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Clinical outcomes of EUS-guided radiofrequency ablation for unresectable pancreatic cancer: A prospective observational study
p. 68
Dongwook Oh, Dong-Wan Seo, Tae Jun Song, Do Hyun Park, Sung Koo Lee, Myung-Hwan Kim
DOI
:10.4103/EUS-D-21-00049
PMID
:35083978
Background and Objectives:
EUS-guided radiofrequency ablation (EUS-RFA) has been increasingly used for the treatment of pancreatic neoplasms. The role of EUS-RFA in the management of pancreatic cancer has not yet been elucidated. This study aimed to evaluate the survival impact of EUS-RFA in unresectable pancreatic cancer.
Methods:
Twenty-two patients (
n
= 14, locally advanced unresectable;
n
= 8, metastatic) with unresectable pancreatic cancer underwent EUS-RFA combined with subsequent chemotherapy between May 2016 and June 2019. Survival outcomes including overall survival (OS) and progression-free survival (PFS) were evaluated.
Results:
EUS-RFA was successful in all patients. The median number of RFA sessions was 5 (interquartile range, [IQR], 3.25–5.75). After successful EUS-RFA, subsequent gemcitabine-based chemotherapy was performed. Early procedure-related adverse events occurred in 4 out of 107 sessions (3.74%), including peritonitis (
n
= 1) and abdominal pain (
n
= 3). During follow-up over a median of 21.23 months (IQR, 10.73–27.1), the median OS and PFS were 24.03 months (95% confidence interval [CI], 16–35.8) and 16.37 months (95% CI, 8.87–19), respectively.
Conclusions:
EUS-RFA is technically feasible and safe for the management of unresectable pancreatic cancer. EUS-RFA combined with systemic chemotherapy may be associated with favorable survival outcomes. Further larger-scale prospective comparative study is required to confirm these findings.
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IMAGES AND VIDEOS
EUS-guided antegrade metal stent deployment using a novel fully covered metal stent with a fine gauge stent delivery system (with video)
p. 75
Takeshi Ogura, Saori Ueno, Atsushi Okuda, Nobu Nishioka, Kazuhide Higuchi
DOI
:10.4103/EUS-D-20-00257
PMID
:34259216
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Jaundice and double-duct sign: Always cancer?
p. 77
Diane Lorenzo, Laurine Verset, Jacques Devière
DOI
:10.4103/EUS-D-20-00240
PMID
:34213430
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EUS-guided fiducial gold marker placement in metastatic colon cancer to the spleen
p. 79
Ameya Deshmukh, Ahmed Mohammed Elmeligui, Hussein Hassan Okasha, Nasim Parsa, Javier Tejedor-Tejada, Jose Nieto
DOI
:10.4103/EUS-D-21-00023
PMID
:34213433
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Right-sided EUS-guided hepaticogastrostomy with delayed stent migration treated with surgical removal (with video)
p. 81
Thanawat Luangsukrerk, Krit Kitisin, Prooksa Ananchuensook, Kulwadee Vanduangden, Kamin Harinwan, Pradermchai Kongkam
DOI
:10.4103/EUS-D-21-00002
PMID
:33975990
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LETTERS TO EDITOR
Preliminary experience of EUS-guided pancreatic fluid collections drainage using a new lumen-apposing metal stent mounted on a cautery device
p. 84
Alberto Larghi, Stefano Francesco Crinò, Giuseppe Vanella, Gianenrico Rizzatti, Laura Bernardoni, Paolo Giorgio Arcidiacono
DOI
:10.4103/EUS-D-21-00033
PMID
:34755703
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String sign: Can we make it more scientific?
p. 86
Iyad Khamaysi, Gadeer A'li Taha, Efad Weishahi, Eyal Zussman
DOI
:10.4103/EUS-D-21-00079
PMID
:34494589
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