In early April 2020, the 3-month-long city-wide lockdown was lifted in Wuhan, the epicenter of China during Coronavirus Disease 2019 (COVID-19) global pandemic. However, continuing precautions are still practiced considering the risk of transmission from asymptomatic carriers. Given that COVID-19 is spread via airborne droplets, including aspiration of oral and fecal material through endoscopes, our endoscopy center has strategically assigned health-care providers to ensure triage workflow and to minimize concomitant exposure from potential asymptomatic carriers. Here, we share the experience of performing EUS-FNA during the COVID-19 pandemic and postendemic periods. We illustrate our workflow using a patient with a left adrenal mass as an example and followed a biosafety level-2 standard. We believe all endoscopy centers need to focus on these three directions: (1) pre-EUS patients risk assessment and triage, (2) Personal protective equipment (PPE), and (3) dressing code modalities. We fully adopted them in our hospital to reduce COVID-19 resurgence risk.

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Background and Objectives: Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units. Methods: A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting. Results: EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up. Conclusions: Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.

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EUS has opened a new frontier in endoscopic techniques for accessing pancreatic ducts in patients with failed ERCP. The major indications of EUS-guided pancreatic duct intervention (EUS-PDI) are main pancreatic duct (MPD) strictures due to chronic pancreatitis or strictures of pancreaticojejunal or pancreaticogastric anastomosis after Whipple resection, which lead to recurrent acute pancreatitis. EUS-guided pancreaticogastro or duodenostomy offers an alternative to surgery when transpapillary drainage fails or is not possible. We provide an expert commentary and a brief overview on this relatively novel technique utilizing EUS-PDI creation in patients with impaired drainage of the MPD who have failed other conventional endoscopic techniques for MPD drainage and either are poor surgical candidates or are reluctant to undergo surgery.

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Background and Objectives: The European Society for Medical Oncology suggests performing EUS staging for esophagogastric junction and gastric cancers to further assess the T and N stages. The use of EUS after neoadjuvant therapy (NT) is still under debate. We aimed to evaluate the contribution of EUS after NT to staging, therapeutic choices, and prognosis prediction. Subjects and Methods: In 97 patients with esophagogastric junction and gastric cancers who received NT (chemotherapy or radiochemotherapy) followed by carcinologic surgery, EUS was performed before (uT, uN) and after (yuT, yuN) NT. We compared the results of EUS staging after NT (yuT and yuN) and final histology (ypT and ypN). We analyzed the correlation between overall survival (OS), disease-free survival (DFS), and the objective and subjective responses to NT evaluated by EUS (comparison of uT and yuT and uN and yuN with OS and DFS). Results: EUS staging detected metastasis that went undetected by computed tomography in 16% of metastatic patients. The accuracy between EUS after NT and postoperative pathological findings was 44.4% (34.2%; 54.7%) for T stage and 49.3% (37.5%; 61.1%) for N stage. On multivariate analysis, OS had significantly correlated with the objective response to NT. In the case of a response to NT, the median OS was 64.77 months, and in the case of stable disease, the median OS was 22.9 months (P = 0.01). Conclusion: EUS after NT can be used for staging. Despite its moderate accuracy, the evaluation of the response to NT by EUS seems to be correlated with patient prognosis.

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Background and Objectives: Concomitant biliary and duodenal malignant obstruction are a severe condition mainly managed by duodenal and biliary stenting, which can be performed simultaneously (SAMETIME) or in two distinct procedures (TWO-TIMES). We conducted a single-center retrospective study to evaluate the feasibility of a SAMETIME procedure and the impact of endoscopic ultrasound (EUS)-hepaticogastrostomy in double malignant obstructions. Patients and Methods: From January 1, 2011, to January 1, 2018, patients with concomitant malignant bilioduodenal obstruction treated endoscopically were included. The primary endpoint was hospitalization duration. The secondary endpoints were bilioduodenal reintervention rates, adverse event rates, and overall survival. Patients were divided into groups for statistical analysis: (i) divided according to the timing of biliary drainage: SAMETIME vs. TWO-TIMES group, (ii) divided based on the biliary drainage method: EUS-HG group underwent hepaticogastrostomy, while DUODENAL ACCESS group underwent endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic drainage (PCTD) or EUS-guided choledocoduodenostomy (EUS-CD). Results: Thirty-one patients were included (19 women, median age = 71 years). Stenosis was mainly related to pancreatic cancer (17 patients, 54.8%). Sixteen patients were in the SAMETIME group, and 15 were in the TWO-TIMES group. Biliary drainage was performed by EUS-HG in 11 (35.%) patients, PCTD in 11 (35.%), ERCP in 8 (25.8%) and choledoduodenostomy in 1. Thirty patients died during follow-up. The median survival was 77 days (9% confidence interval [37–140]). The mean hospitalization duration was lower in the SAMETIME group: 7.5 vs. 12.6 days, P = 0.04. SAMETIME group patients tended to have a lower complication than TWO-TIMES (26.7% vs. 56.3%, P = 0.10). The EUS-HG group tended to have a lower complication rate (5% vs. 18.2%, P = 0.07) and less biliary endoscopic revision (30% vs. 9.1%, P = 0.37) than DUODENAL ACCESS. Conclusions: SAMETIME drainage is associated with a lower hospital stay without increased morbidity. EUS-HG could provide better access because it did not exhibit a higher complication rate and showed a tendency toward better patency and fewer complications.

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Background and Objectives: Differential diagnosis to estimate the malignant potential of gastric submucosal tumor (g-SMT) is important for decision-making. This study evaluated the use of a 20G needle with a core trap for EUS-guided fine-needle biopsy (EUS-FNB) for g-SMT. Methods: This multicentric prospective trial was registered in the University Hospital Medical Information Network (UMIN000021410). Consecutive patients with g-SMT who presented at one of the nine Japanese Referral Centers between June 2017 and November 2018 were enrolled. All patients underwent EUS-FNB using a 20G needle with a core trap. Samples obtained with the first-needle pass were used for central pathological review. EUS-FNB was evaluated in terms of (i) technical success rate, (ii) adequacy for histological evaluation, (iii) rate of complications, (iv) accuracy for histological diagnosis of gastrointestinal stromal tumor (GIST), and (v) concordance between GIST mitotic index determined by EUS-FNB and after tumor resection. Results: The study included 52 patients. The technical success rate of EUS-FNB was 100%. The adequacy rate for histological evaluation was 90.4% (P < 0.001). There were no complications related to EUS-FNB. Of the 38/52 patients who underwent surgical resection, 36 were finally diagnosed with GIST. The sensitivity, specificity, and accuracy of EUS-FNB for the histological diagnosis of g-SMT were 80.6%, 100%, and 81.6%, respectively. The concordance rate between the mitotic index on EUS-FNB and that after analysis of the resected tumor was 89.7%. Conclusions: EUS-FNB using a 20G needle with a core trap is feasible, providing histological samples of sufficient quality for diagnosing g-SMT.

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Background and Objectives: Rapid on-site cytologic evaluation (ROSE) increases the diagnostic yield of EUS-FNA. However, ROSE requires the presence of a cytopathologist and additional cost and time for slide staining and interpretation. Macroscopic on-site examination (MOSE) was recently introduced as an alternative to ROSE and showed high accuracy for the use in pathologic diagnosis. We evaluated the efficacy of MOSE in terms of tissue acquisition and diagnostic accuracy for abdominal lesions. Methods: We analyzed consecutive patients included who underwent EUS-guided fine needle biopsy (FNB) between January 2019 and November 2019. All procedures were done by dry suction using a 22G needle. Obtained specimens were expelled onto filter papers and evaluated by MOSE. Needle pass was done until the acquisition of satisfactory whitish macroscopic visible core or bloody tissue granules. The primary outcomes were successful tissue acquisition and accuracy for pathologic diagnosis. Results: In 75 patients (male, 52%; median age: 62 years), the pancreas was the most commonly targeted organ (81.4%) and the median target diameter was 25 mm. The median number of needle passes was 2.0 (range, 2–5). Successful targeting of the lesion was achieved in 75 patients (100%) and overall accuracy was 97.3%. There were no procedure-related adverse events. Conclusions: MOSE was effective for complementing EUS-FNB by ensuring the adequate acquisition of biopsy specimens with a minimal number of needle passes while providing a critically high diagnostic accuracy. MOSE seems to be a viable alternative to ROSE in select clinical situations.

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Background and Objectives: The accuracy of EUS and endoscopic pancreatic function test (ePFT) for diagnosis of early or minimal-change chronic pancreatitis (MCCP) is poorly understood. We hypothesized that the natural history of the disease may be used as a “gold standard” to assess the ability of EUS and ePFT to predict the eventual development of overt chronic pancreatitis (CP) changes on computed tomography/magnetic resonance cholangiopancreatography (CT/MRCP). The aim of the study was to determine the ability of EUS and ePFT to predict disease progression in patients with suspected MCCP who had nondiagnostic baseline imaging. Methods: A retrospective cohort study was conducted. Patients who underwent EUS and ePFT for suspected CP and who had nondiagnostic CT or MRCP were included. Patients without repeat imaging performed more than 1 year after their initial EUS/ePFT were excluded. Imaging was considered diagnostic if calcifications, main duct dilation (Cambridge Class III/IV), or severe atrophy were identified. Patients lost to follow-up were contacted to complete a survey documenting current symptoms and whether patients progressed to CP based on imaging. Univariable and multivariable analyses were performed using Cox regression. Results: Two hundred and thirty patients who underwent EUS/ePFT for suspected MCCP were identified between 2006 and 2012. Of these, 90 had a non-diagnostic baseline imaging test and subsequently a follow-up imaging test greater than 1 year later. These 90 patients constituted our study population. During a mean follow-up of 7 years, 19 (21%) patients developed CP by histology and imaging. Abnormal ePFT (peak bicarbonate <80 mmol) was a significant predictor of progression (hazard ratio [HR]: 4.7, confidence interval [CI]: 1.8, 12.4). Likewise, EUS Rosemont classification “suggestive/most-consistent” was a significant predictor of progression (HR: 7.3, CI: 2.4, 22.1). Conclusions: In patients with abdominal pain of suspected pancreatic origin and with nondiagnostic cross-sectional imaging, EUS and ePFT results predict the development of classic CP structural changes over time. These results support EUS and ePFT as effective tools for predicting progression of minimal change to overt CP.

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