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   2022| May-June  | Volume 11 | Issue 3  
    Online since June 15, 2022

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Controversies in ERCP: Indications and preparation
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
May-June 2022, 11(3):186-200
DOI:10.4103/EUS-D-21-00106  PMID:34677145
The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.
  2,190 147 -
Adverse events associated with AXIOS stents: Insights from the manufacturer and user facility device experience database
Daryl Ramai, Antonio Facciorusso, Matthew DeLuca, Monique Barakat, Douglas G Adler
May-June 2022, 11(3):231-236
DOI:10.4103/EUS-D-21-00096  PMID:35083979
Background and Objectives: The AXIOS stent is indicated for transgastric or transduodenal drainage of symptomatic pancreatic pseudocysts and symptomatic walled off necrosis. The AXIOS stent functions as a conduit which allows solid and liquid pancreatic fluid collections (PFC) contents to pass into the luminal GI tract and also allows the passage of standard and therapeutic endoscopes into the PFC to perform endoscopic debridement. We aim to investigate the number and type of complications associated with AXIOS stents. Materials and Methods: We analyzed postmarketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database January 2016 to February 2021. Results: During the study period, approximately 588 reports with 579 device issues and 250 patient complications were identified. Most device complications were due to stent positioning problems or stent malpositioning (n = 206; 35.6%), followed by stent migration (n = 72; 12.4%), premature deployment (n = 61; 10.5%), material integrity (n = 56; 9.6%), deployment failure (n = 47; 8.1%), and difficulty removing the stent (n = 45; 7.7%). The most reported patient adverse events were hemorrhage/bleeding (n = 81; 32.4%), perforation (n = 26; 10.4%), pain (n = 22; 8.8%), unspecified infection (n = 20; 8.0%), and death (n = 17; 6.8%). Conclusions: Findings from the MAUDE database highlight patient and device complications which endoscopists should be aware of before AXIOS stent placement.
  2,059 71 -
Comparison of EUS-guided choledochoduodenostomy and percutaneous drainage for distal biliary obstruction: A multicenter cohort study
Tarek Sawas, Natashay J Bailey, Kit Ying Kitty Au Yeung, Theodore W James, Sumana Reddy, Chad J Fleming, Neil B Marya, Andrew C Storm, Barham K Abu Dayyeh, Bret T Petersen, John A Martin, Michael J Levy, Todd H Baron, Anthony Yuen Bun Teoh, Vinay Chandrasekhara
May-June 2022, 11(3):223-230
DOI:10.4103/EUS-D-21-00031  PMID:35102902
Background and Objectives: Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival. Methods: A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO). Results: A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12–1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02–0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival. Conclusion: EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days.
  2,048 81 -
Differential EUS findings in focal type 1 autoimmune pancreatitis and pancreatic cancer: A proof-of-concept study
Matteo Tacelli, Piera Zaccari, Maria Chiara Petrone, Emanuel Della Torre, Marco Lanzillotta, Massimo Falconi, Claudio Doglioni, Gabriele Capurso, Paolo Giorgio Arcidiacono
May-June 2022, 11(3):216-222
DOI:10.4103/EUS-D-21-00111  PMID:35142701
Background and Objectives: Autoimmune pancreatitis (AIP) often mimics pancreatic cancer (PC), particularly if presenting as a focal lesion. EUS may orient the differential diagnosis between them. This study aims to identify EUS findings that might be useful to differentiate type 1 focal autoimmune pancreatitis (f-AIP1) and PC. Materials and Methods: F-AIP1 and PC patients were retrospectively collected, matched, and compared. EUS findings considered were: focal mass echogenicity, loss of lobularity, distal atrophy, peripancreatic hypoechoic margins (PHM), pancreatic duct dilation, duct-penetrating sign (DPS), pancreatic/common bile duct thickened walls (PD/CBD-TW), and vessel infiltration (VI). Elastography findings were also recorded. Variables with a P < 0.05 at univariate analysis were included in logistic multiple regression. Results: Fifteen patients with f-AIP and 60 with PC were studied. FE was hypoechoic in all patients from both groups. PHM was observed in 40% of f-AIP1 cases but not in PC ones (P < 0.001). DPS was found in 10/15 (66.7%) f-AIP1 and in 7/60 (11.7%) PC patients (P < 0.001). PD-TW and CBD-TW were observed in 66.7%/60% f-AIP1 cases and in 6.7%/13.6% PC patients, respectively (P < 0.001 for both comparisons). Pancreatic masses were significantly different at EUS elastography (elastic respectively in 71.4% f-AIP1 and 3.8% PC, P < 0.001). VI was suspected in 20% of f-AIPs and 85% of PCs (P < 0.001). At multiple regression, PD-TW, CBD-TW, elastic pattern, and the absence of VI independently supported a diagnosis of f-AIP1. Conclusions: Our results suggest that EUS findings deserve consideration in the diagnostic workup of AIP to improve the differential diagnosis with PC.
  1,771 75 -
Pooled diagnostic parameters of artificial intelligence in EUS image analysis of the pancreas: A descriptive quantitative review
Babu P Mohan, Antonio Facciorusso, Shahab R Khan, Deepak Madhu, Lena L Kassab, Suresh Ponnada, Saurabh Chandan, Stefano F Crino, Gursimran S Kochhar, Douglas G Adler, Michael B Wallace
May-June 2022, 11(3):156-169
DOI:10.4103/EUS-D-21-00063  PMID:35313417
EUS is an important diagnostic tool in pancreatic lesions. Performance of single-center and/or single study artificial intelligence (AI) in the analysis of EUS-images of pancreatic lesions has been reported. The aim of this study was to quantitatively study the pooled rates of diagnostic performance of AI in EUS image analysis of pancreas using rigorous systematic review and meta-analysis methodology. Multiple databases were searched (from inception to December 2020) and studies that reported on the performance of AI in EUS analysis of pancreatic adenocarcinoma were selected. The random-effects model was used to calculate the pooled rates. In cases where multiple 2 × 2 contingency tables were provided for different thresholds, we assumed the data tables as independent from each other. Heterogeneity was assessed by I2% and 95% prediction intervals. Eleven studies were analyzed. The pooled overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 86% (95% confidence interval [82.8–88.6]), 90.4% (88.1–92.3), 84% (79.3–87.8), 90.2% (87.4–92.3) and 89.8% (86–92.7), respectively. On subgroup analysis, the corresponding pooled parameters in studies that used neural networks were 85.5% (80–89.8), 91.8% (87.8–94.6), 84.6% (73–91.7), 87.4% (82–91.3), and 91.4% (83.7–95.6)], respectively. Based on our meta-analysis, AI seems to perform well in the EUS-image analysis of pancreatic lesions.
  1,652 110 -
EUS-guided radiofrequency and ethanol ablation for pancreatic neuroendocrine tumors: A systematic review and meta-analysis
Rajat Garg, Abdul Mohammed, Amandeep Singh, Mary P Harnegie, Tarun Rustagi, Tyler Stevens, Prabhleen Chahal
May-June 2022, 11(3):170-185
DOI:10.4103/EUS-D-21-00044  PMID:35313416
EUS-guided radiofrequency ablation (RFA) and ethanol ablation (EA) for pancreatic neuroendocrine tumors (PNETs) have recently been reported with good outcomes. We performed a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of EUS-RFA and EUS-EA in the treatment of PNETs. A comprehensive search of multiple databases (through October 2020) was performed to identify studies that reported outcomes of EUS-RFA and EUS-EA of PNETs. Outcomes assessed included clinical success, technical success, and adverse events (AEs). A total of 181 (100 EUS-RFA, 81 EUS-EA) patients (60.7 ± 9.2 years) with 204 (113 EUS-RFA, 91 EUS-EA) PNETs (mean size 15.1 ± 4.7 mm) were included from 20 studies. There was no significant difference in the rates of technical success (94.4% [95% confidence interval (CI): 88.5–97.3, I2 = 0] vs. 96.7% [95% CI: 90.8–98.8, I2 = 0]; P = 0.42), clinical success (85.2% (95% CI: 75.9–91.4, I2 = 0) vs. 82.2% [95% CI: 68.2–90.8, I2 = 10.1]; P = 0.65), and AEs (14.1% [95% CI: 7.1–26.3, I2 = 0] vs. 11.5% [95% CI: 4.7–25.4, I2 = 63.5]; P = 0.7) between EUS-RFA and EUS-EA, respectively. The most common AE was pancreatitis with the rate of 7.8% and 7.6% (P = 0.95) for EUS-RFA and EUS-EA, respectively. On meta-regression, the location of PNETs in head/neck of pancreas (P = 0.03) was a positive predictor of clinical success for EUS-RFA. EUS-RFA and EUS-EA have similar effectiveness and safety for PNETs ablation. Head/neck location of PNETs was a positive predictor for clinical success after EUS-RFA.
  1,621 116 -
EUS-guided hepaticogastrostomy with contrast-enhanced harmonic imaging (with video)
Takashi Tamura, Masayuki Kitano, Keiichi Hatamaru
May-June 2022, 11(3):241-242
DOI:10.4103/EUS-D-21-00107  PMID:35083980
  1,142 51 -
EUS-FNA of a lesion in the pancreatic head using a forward-viewing echoendoscope in a patient with Billroth II gastrectomy (with video)
Ting-Ting Gong, Min-Min Zhang, Duo-Wu Zou
May-June 2022, 11(3):243-245
DOI:10.4103/EUS-D-21-00101  PMID:35017384
  952 45 -
Hot topics in therapeutic EUS
Daniela Tabacelia, Alexandru Martiniuc, Daniela Elena Burtea, Adrian Saftoiu, Cezar Stroescu
May-June 2022, 11(3):153-155
  760 149 -
Evaluation of the ex-vivo porcine simulator on EUS-guided cystogastrostomy using lumen-apposing metal stent training
Mostafa Ibrahim, Noran Roshdy, Amerah Taleb, Abdulrahman Alfadda, Abed Al-Lehibi, Ahmed Altonbary, Ahmed Galal, Amr El-Fouly, Anna Kozlowska, Christopher Khor, Hiroyuki Isayama, Hussein Okasha, Marc Barthet, Marc Giovannini, Nonthalee Pausawasdi, Pierre Eisendrath, Pradermchai Kongkam, Thawee Ratanachu-ek, Yousuke Nakai
May-June 2022, 11(3):201-207
Bckground and Objectives: EUS-guided cystogastrostomy is a well-established advanced endoscopic technique with a steep-learning curve which necessitates an ex-vivo simulator that would allow for adequate training. The aim of this study is to evaluate the feasibility of the model in allowing training for EUS-guided cystogastrostomy using lumen-apposing metal stent (LAMS). Subjects and Methods: The model was created by ROEYA Training Center, Egypt, using native porcine tissue to create fluid collections simulating both cystic and solid lesions. It was designed and tested in advance while the hydrogel was added on-site. The simulator was evaluated prospectively in five training sessions involving 17 international experts. The task was to successfully deploy the LAMS to drain the created cyst. After using the simulator, the experts were asked to fill a questionnaire to assess their experience. The primary endpoint was overall satisfaction with the model as a training tool. Results: All of the experts were satisfied with the model as a tool to train endoscopists for the technique. 76.5% (n = 11) of the experts thought the model to be moderately realistic. Proper visualization was reported by 94.1% of the experts. All experts believed the lesions to be either slightly like or very similar to real lesions. The model was graded “easy” in difficulty by 11 of the experts. Conclusions: In all parameters assessed, the experts thought the model to be a useful tool for future training. This preliminary study suggests that the aforementioned simulator can be used to train endoscopists on using LAMS in a risk-free environment.
  635 61 -
Independent risk factors for true malignancy in atypical cytologic diagnostic category in EUS-FNA/FNB of the pancreas: A novel prediction model
Ping-Ping Zhang, Teng Wang, Shi-Yu Li, Li Li, Xiao-Ju Su, Pei-Yuan Gu, Yi-Ping Qian, Feng Li, Li Gao, Zhen-Dong Jin, Kai-Xuan Wang
May-June 2022, 11(3):208-215
Background and Objects: An atypical cytologic diagnosis arises from inflammation or early neoplastic process. It is commonly found in EUS-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) tissue sampling of pancreatic malignancies. The aims of this study were to evaluate the diagnostic performance of EUS-FNA/FNB in patients with cytologic diagnosis of atypical cells and to develop a prediction model for malignant tumors of the pancreas in the atypical cytologic diagnostic category. Methods: Two hundred and twenty-six patients in the atypical cytologic diagnostic category were analyzed. Multivariate logistic regression analyses were performed to determine predictive factors for pancreatic malignancies. The final diagnoses were confirmed by repeat biopsy; surgical pathology, or clinical follow-up for at least 6 months. Results: The atypical cytologic diagnosis using EUS-FNA/FNB was associated with an absolute risk of malignancy (82.3%). Multivariate logistic regression analyses revealed that older age, long axis of the mass, and increased carbohydrate antigen 19-9 (CA19-9) were independent risk factors for true malignant pancreatic tumors among patients in the atypical cytologic diagnostic category. The calibration curve had a slope of 0.96, and a regression coefficient (R2) of 0.91. The area under the receiver operating characteristic curve of the validation group was 0.803. Conclusions: Atypical lesions of EUS-FNA/FNB have a higher risk of malignancy. Older age, the long axis of the mass, and elevated serum CA19-9 level were identified as independent risk factors for true malignant pancreatic tumors among patients in the atypical cytologic diagnostic category.
  628 36 -
Milky way
Moiz Ahmed, Nirali Sheth, Raghav Bansal, Krishna C Gurram, Joshua Aron
May-June 2022, 11(3):239-240
DOI:10.4103/EUS-D-21-00047  PMID:35435338
  458 39 -
Altered anatomy: An EUS-guided placement of a lumen-apposing metal stent for successful ERCP following Whipple procedure (with video)
Kazi I Ullah, Meera Bhardwaj, Sammy Ho
May-June 2022, 11(3):237-238
  430 50 -
Forward-viewing EUS-guided combined coil and glue injection in bleeding gastric varices secondary to splenic vein thrombosis in chronic pancreatitis
Surinder Singh Rana, Nikhil Bush, Ravi Sharma, Lovneet Dhalaria, Rajesh Gupta
May-June 2022, 11(3):246-247
  408 36 -