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Verloop CA, Goos JAC, Bruno MJ, Quispel R, van Driel LMJW, Hol L. Diagnostic yield of endoscopic and EUS-guided biopsy techniques in subepithelial lesions of the upper GI tract: a systematic review. Gastrointest Endosc 2024; 99:895-911.e13. [PMID: 38360118 DOI: 10.1016/j.gie.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND AIMS Obtaining adequate tissue samples in subepithelial lesions (SELs) remains challenging. Several biopsy techniques are available, but a systematic review including all available techniques to obtain a histologic diagnosis of SEL is lacking. The aim of this study was to evaluate the diagnostic yield and adverse event rates of endoscopic biopsies, EUS-guided FNA (EUS-FNA), EUS-guided fine-needle biopsy (FNB) (EUS-FNB), and mucosal incision-assisted biopsy (MIAB) for SELs in the upper GI tract. METHODS A search strategy in multiple databases was performed. The primary outcome was diagnostic yield, defined as the percentage of procedures in which histology was obtained and resulted in a definitive histopathologic diagnosis. Secondary outcome measures included reported procedure-related adverse events, which were graded according to the AGREE (Adverse Events in Gastrointestinal Endoscopy) classification. RESULTS A total of 94 original articles were included. Studies were classified per endoscopic technique to obtain histopathology. This resulted in 8 included studies for endoscopic biopsy methods, 55 studies for EUS-FNA, 33 studies for EUS-FNB, and 26 studies for MIAB. Pooled rates for diagnostic yield were 40.6% (95% confidence interval [CI], 30.8-51.2) for endoscopic biopsy, 74.6% (95% CI, 69.9-78.7) for EUS-FNA, 84.2% (95% CI, 80.7-87.2) for EUS-FNB, and 88.2% (95% CI, 84.7-91.1) for MIAB. Reported procedure-related adverse events graded AGREE II or higher were 2.8% to 3.9% for endoscopic biopsies, 1.0% to 4.5% for EUS-FNA, .9% to 7.7% for EUS-FNB, and 1.9% to 7.9% for MIAB. CONCLUSIONS Based on the available evidence, MIAB and EUS-FNB seem to be most effective in terms of achieving a high diagnostic yield, with similar rates of adverse events.
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Affiliation(s)
- Cynthia A Verloop
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands.
| | - Jacqueline A C Goos
- Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus University Medical Centre, Rotterdam the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf hospital, Delft, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology, Erasmus University Medical Centre, Rotterdam the Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
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Seven G, Silahtaroglu G, Seven OO, Senturk H. Differentiating Gastrointestinal Stromal Tumors from Leiomyomas Using a Neural Network Trained on Endoscopic Ultrasonography Images. Dig Dis 2022; 40:427-435. [PMID: 34619683 PMCID: PMC9393815 DOI: 10.1159/000520032] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Endoscopic ultrasonography (EUS) is crucial to diagnose and evaluate gastrointestinal mesenchymal tumors (GIMTs). However, EUS-guided biopsy does not always differentiate gastrointestinal stromal tumors (GISTs) from leiomyomas. We evaluated the ability of a convolutional neural network (CNN) to differentiate GISTs from leiomyomas using EUS images. The conventional EUS features of GISTs were also compared with leiomyomas. PATIENTS AND METHODS Patients who underwent EUS for evaluation of upper GIMTs between 2010 and 2020 were retrospectively reviewed, and 145 patients (73 women and 72 men; mean age 54.8 ± 13.5 years) with GISTs (n = 109) or leiomyomas (n = 36), confirmed by immunohistochemistry, were included. A total of 978 images collected from 100 patients were used to train and test the CNN system, and 384 images from 45 patients were used for validation. EUS images were also evaluated by an EUS expert for comparison with the CNN system. RESULTS The sensitivity, specificity, and accuracy of the CNN system for diagnosis of GIST were 92.0%, 64.3%, and 86.98% for the validation dataset, respectively. In contrast, the sensitivity, specificity, and accuracy of the EUS expert interpretations were 60.5%, 74.3%, and 63.0%, respectively. Concerning EUS features, only higher echogenicity was an independent and significant factor for differentiating GISTs from leiomyomas (p < 0.05). CONCLUSIONS The CNN system could diagnose GIMTs with higher accuracy than an EUS expert and could be helpful in differentiating GISTs from leiomyomas. A higher echogenicity may also aid in differentiation.
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Affiliation(s)
- Gulseren Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Gokhan Silahtaroglu
- Management Information Systems Department, School of Business and Management Science, Istanbul Medipol University, Istanbul, Turkey
| | - Ozden Ozluk Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Hakan Senturk
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey,*Hakan Senturk,
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Kang S, Kim DH, Kim Y, Jeon D, Na HK, Lee JH, Ahn JY, Jung KW, Choi KD, Song HJ, Lee GH, Jung HY. Natural History of Asymptomatic Esophageal Subepithelial Tumors of 30 mm or Less in Size. J Korean Med Sci 2022; 37:e184. [PMID: 35698837 PMCID: PMC9194489 DOI: 10.3346/jkms.2022.37.e184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/16/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs. METHODS Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed. RESULTS Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas. CONCLUSION Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection.
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Affiliation(s)
- Seokin Kang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Yuri Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dongsub Jeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Use of Artificial Intelligence in the Prediction of Malignant Potential of Gastric Gastrointestinal Stromal Tumors. Dig Dis Sci 2022; 67:273-281. [PMID: 33547537 DOI: 10.1007/s10620-021-06830-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/07/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS This study aimed to investigate whether AI via a deep learning algorithm using endoscopic ultrasonography (EUS) images could predict the malignant potential of gastric gastrointestinal stromal tumors (GISTs). METHODS A series of patients who underwent EUS before surgical resection for gastric GISTs were included. A total of 685 images of GISTs from 55 retrospectively included patients were used as the training data set for the AI system. Convolutional neural networks were constructed to build a deep learning model. After applying the synthetic minority oversampling technique, 70% of the generated images were used for AI training and 30% were used to test AI diagnoses. Next, validation was performed using 153 EUS images of 15 patients with GISTs. In addition, conventional EUS features of 55 patients in the training cohort were evaluated to predict the malignant potential of GISTs and mitotic index. RESULTS The overall sensitivity, specificity, and accuracy of the AI system for predicting malignancy risk were 83%, 94%, and 82% in the training dataset, and 75%, 73%, and 66% in the validation cohort, respectively. When patients were divided into low-risk and high-risk groups, sensitivity, specificity, and accuracy increased to 99% in the training dataset and 99.7%, 99.7%, and 99.6%, respectively, in the validation cohort. No conventional EUS features were found to be associated with either malignant potential or mitotic index (P > 0.05). CONCLUSIONS AI via a deep learning algorithm using EUS images could predict the malignant potential of gastric GISTs with high accuracy.
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Codipilly DC, Fang H, Alexander JA, Katzka DA, Ravi K. Subepithelial esophageal tumors: a single-center review of resected and surveilled lesions. Gastrointest Endosc 2018; 87:370-377. [PMID: 28782509 DOI: 10.1016/j.gie.2017.07.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Subepithelial esophageal tumors (SETs) are frequent incidental findings. Although symptomatic tumors are surgically or endoscopically resected, there is no consensus on the management of asymptomatic esophageal leiomyomas. METHODS Appropriate International Classification of Diseases, Ninth Revision codes followed by medical record review were used to identify patients with SETs from January 1992 to March 2017, with abstraction of basic demographics, surveillance intervals, and mortality. Patients were contacted to complete a phone questionnaire to assess follow-up as well as the validated Brief Esophageal Dysphagia Questionnaire (BEDQ). RESULTS Eighty-four leiomyomas, 5 leiomyosarcomas, 13 GI stromal tumors (GISTs), and 4 granular cell tumors were found. Among patients with leiomyomas, 58 (69%) were resected and 26 (31%) were followed under surveillance. Resected esophageal leiomyomas were larger than those under surveillance (49.7 mm vs 17.9 mm, P < .003). Esophageal leiomyoma growth during surveillance was only .5 mm over a mean 70-month follow-up (range, 4-288). No malignant transformation was seen, and only 2 patients required subsequent resection. The phone survey was completed by 35 patients and revealed minimal symptom burden, with only 2 patients (15%) under esophageal leiomyoma surveillance reporting symptoms (BEDQ score ≥10) over a mean 96.7-month follow-up. EUS had high diagnostic accuracy with a positive predictive value of 68% and a negative predictive value of 100% for leiomyomas or GISTs compared with surgical pathology. CONCLUSIONS EUS demonstrated high diagnostic accuracy in resected SETs. Esophageal leiomyomas demonstrate minimal growth or symptomatic progression. Therefore, long-term EUS surveillance of small asymptomatic esophageal leiomyomas may be unnecessary.
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Affiliation(s)
- Don C Codipilly
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hongfei Fang
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Perwaiz A, Shaw VK, Singh A, Chaudhary A. Extra-mucosal enucleation is still a safe and feasible treatment option of giant esophageal leiomyomas. Indian J Gastroenterol 2018; 37:63-66. [PMID: 29464545 DOI: 10.1007/s12664-018-0835-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
Esophageal leiomyoma (EL) is rare but still the most common benign tumor of the esophagus. Extra-mucosal enucleation (EME) is the treatment of choice. Many recent reports have favored esophageal resection for giant Esophageal leiomyomas (ELs). The consequence of esophageal resection is well known and it would be radical to consider it as a preferred treatment for giant EL since most of them are still benign. We share case series of five giant ELs managed by EME, avoiding a mucosal breach and hence avoiding potentially morbid esophageal resections.
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Affiliation(s)
- Azhar Perwaiz
- Department of GI Surgery, GI Oncology, MAS and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon, 122 018, India.
| | - Vinay Kumar Shaw
- Department of GI Surgery, GI Oncology, MAS and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon, 122 018, India
| | - Amanjeet Singh
- Department of GI Surgery, GI Oncology, MAS and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon, 122 018, India
| | - Adarsh Chaudhary
- Department of GI Surgery, GI Oncology, MAS and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon, 122 018, India
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Baysal B, Masri OA, Eloubeidi MA, Senturk H. The role of EUS and EUS-guided FNA in the management of subepithelial lesions of the esophagus: A large, single-center experience. Endosc Ultrasound 2017; 6:308-316. [PMID: 26365993 PMCID: PMC5664851 DOI: 10.4103/2303-9027.155772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Referral for endosonographic evaluation of subepithelial lesions seen in the gastrointestinal (GI) tract is fairly common. Although rarely studied separately in details, esophageal lesions have some unique differences from other GI sites and might deserve some special considerations regarding follow-up and management. MATERIALS AND METHODS All cases referred for endoscopic ultrasound (EUS) evaluation of subepithelial esophageal lesions at Bezmialem University Hospital, a tertiary center in Istanbul, Turkey were retrospectively reviewed. Data were collected for patient and lesion characteristics as well as for pathology results and follow-up if available. Lesions were subcategorized according to their size, location, and final diagnosis. RESULTS A total of 164 EUS examinations were identified. In 22.5% of cases, the lesion could not be identified by EUS. Of the remaining cases, 57.6% had a lesion larger than 1 cm in size. Extramural compression was the diagnosis in 12% and leiomyoma in around 60%. Thirteen patients had follow-up examinations with only two showing an increase in size after 12 months. Sixty-five EUS-guided fine needle aspirations (EUS-guided FNAs) were performed, with around 50% having nondiagnostic samples and 94% of the remaining samples confirming the presumptive diagnosis. CONCLUSIONS The majority of subepithelial lesions in the esophagus are benign with extremely low malignancy potential. EUS examinations performed for lesions smaller than 2 cm as well as FNAs taken from lesions smaller than 3 cm might have minimal impact on their ultimate management and outcome. More than one FNA pass should be attempted in order to improve the yield.
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Affiliation(s)
- Birol Baysal
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakif University Hospital, Istanbul, Turkey
| | - Omar A Masri
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakif University Hospital, Istanbul, Turkey
| | - Mohamad A Eloubeidi
- Department of Gastroenterology, Advanced Endoscopy Unit, Regional Medical Center, Alabama, USA
| | - Hakan Senturk
- Department of Internal Medicine, Division of Gastroenterology, Bezmialem Vakif University Hospital, Istanbul, Turkey
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Dias de Castro F, Magalhães J, Monteiro S, Leite S, Cotter J. The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:287-292. [PMID: 28868481 PMCID: PMC5580021 DOI: 10.1016/j.jpge.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/18/2016] [Indexed: 12/18/2022]
Abstract
Introduction The identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract. Methods Retrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed. Results 324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2 cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p < 0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications. Conclusion EUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.
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Affiliation(s)
- Francisca Dias de Castro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Joana Magalhães
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Sara Monteiro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Sílvia Leite
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Kim EY. Which needle is better for diagnosing subepithelial lesions? Clin Endosc 2015; 48:91-3. [PMID: 25844333 PMCID: PMC4381150 DOI: 10.5946/ce.2015.48.2.91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 01/04/2023] Open
Affiliation(s)
- Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc 2014; 80:939-59.e7. [PMID: 25434654 DOI: 10.1016/j.gie.2014.07.066] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 07/17/2014] [Indexed: 02/08/2023]
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Kim EY. Diagnosis of subepithelial lesion: still "tissue is the issue". Clin Endosc 2013; 46:313-4. [PMID: 23964325 PMCID: PMC3746133 DOI: 10.5946/ce.2013.46.4.313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Affiliation(s)
- Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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