Is ERCP still the elective primary biliary drainage technique in patients with malignant distal biliary obstruction?

Endoscopic retrograde cholangiopancreatography (ERCP) has been established as the first line therapy for the resolution of biliary and pancreatic diseases. The main disadvantage of the procedure is the rate of adverse events, around 10%1. So, despite being a minimally invasive procedure, ERCP has a non-negligible rate of adverse effects (AEs) and secondary mortality.

Managing dysfunctions and reinterventions in endoscopic ultrasound-guided choledochoduodenostomy with lumen apposing metal stents: Illustrated technical review (with videos)

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with lumen apposing metal stent is emerging both as a rescue strategy and a primary treatment for distal malignant biliary obstruction. The large-scale diffusion of the procedure and improved overall survival of patients with pancreatobiliary neoplasms is resulting in a growing population of long-term EUS-CDS lumen apposing metal stent carriers. Recent studies have reported a need for reintervention during follow-up as high as 55%, and the Leuven-Amsterdam-Milan Study Group classification has been developed, identifying five mechanisms of stent dysfunction and 11 possible rescue strategies aimed at restoring biliary drainage. This illustrated technical review aims to further dissect the recent classification through a comprehensive analysis of nine illustrative cases, offering insights into the pathophysiology underlying dysfunction and clinical reasoning behind rescue interventions, as well as technical considerations and practical tips and tricks. By exploring mechanisms of dysfunction, this review also assists clinicians in selecting the ideal candidates for EUS-CDS while identifying patients deemed high risk for dysfunction or clinical failure.

Lumen-apposing metal stents for the treatment of pancreatic and peripancreatic fluid collections and bleeding risk: a propensity matched study

INTRODUCTION

 Endoscopic ultrasound (EUS)-guided drainage of symptomatic pancreatic fluid collections (PFCs) using the Hot-Axios device has recently been associated with a significant risk of bleeding. This adverse event (AE) seems to occur less frequently with the use of a different device, the Spaxus stent. The aim of the current study was to compare the rates of bleeding between the two stents.

METHODS

 Patients admitted for treatment of PFCs by EUS plus lumen-apposing metal stent in 18 endoscopy referral centers between 10 July 2019 and 28 February 2022 were identified and their outcomes compared using a propensity-matching analysis.

RESULTS

 363 patients were evaluated. After a 1-to-1 propensity score match, 264 patients were selected (132 per group). The technical and clinical success rates were comparable between the two groups. Significantly more bleeding requiring transfusion and/or intervention occurred in the Hot-Axios group than in the Spaxus group (6.8% vs. 1.5%; P = 0.03); stent type was a significant predictor of bleeding in both univariate and multivariate regression analyses (P = 0.03 and 0.04, respectively). Bleeding necessitating arterial embolization did not however differ significantly between the two groups (3.0% vs. 0%; P = 0.12). In addition, the Hot-Axios was associated with a significantly higher rate of overall AEs compared with the Spaxus stent (9.8% vs. 3.0%; P = 0.04).

CONCLUSION

 Our study showed that, in patients with PFCs, bleeding requiring transfusion and/or intervention occurred significantly more frequently with use of the Hot-Axios stent than with the Spaxus stent, although this was not the case for bleeding requiring embolization.

A meta-analysis on the efficacy of endoscopic ultrasonography for treatment of pancreatic cancer

OBJECTIVE

This study aimed to systematically evaluate the efficacy and safety of Endoscopic Ultrasonography (EUS) for the treatment of pancreatic cancer.

METHODS

The PubMed, Embase, Web of Science, and Google Scholar databases were searched from the inception of the databases to June 2022. RevMan 5.3.0 software was utilized for data analysis. In total, 13 self-descriptive studies, which enrolled 382 patients, were finally included.

RESULTS

It was revealed that EUS for the treatment of pancreatic cancer exhibited a lower incidence of adverse reactions (Relative Risk Ration [RR = 0.23], 95 % Confidence interval [95 % CI 0.23-0.23]), a higher success rate (RR = 0.90, 95 % CI 0.90-0.90), and a low failure rate (RR = 0.06, 95 % CI 0.06-0.06). Moreover, EUS-guided Celiac Plexus Neurolysis (EUS-CPN) not only significantly relieved pancreatic cancer patients' pain (RR = 0.83, 95 % CI 0.83-0.83), but also significantly eliminated pain in some patients (RR = 0.09, 95 % CI 0.09-0.09). The effects of EUS on pancreatic cancer treatment were satisfactory, and few adverse reactions were found.

CONCLUSION

Owing to the restricted sample size in this meta-analysis, primarily consisting of descriptive studies, it was imperative to conduct more rigorously designed, multi-center, long-term follow-up, larger sample, and Randomized Controlled Trials (RCTs) to validate the findings.

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study

BACKGROUND AND AIM

This study aimed to determine safety and risk factors for adverse events (AEs) of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with long-term indwell of lumen-apposing metal stents (LAMS).

METHODS

This study is a multicenter prospective observational study on consecutive high surgical-risk patients requiring gallbladder drainage who underwent EUS-GBD with LAMS over 12 months. Centralized telephone follow-up interviews were conducted every 3 months for 1 year. Patients were censored at LAMS removal, cholecystectomy, or death. AE-free survival was determined using log-rank tests. Cumulative risks were estimated using life-table analysis.

RESULTS

Eighty-two patients were included (53.7% male, median [interquartile range] age of 84.6 [76.5-89.8] years, and 85.4% with acute cholecystitis). Technical success was achieved in 79 (96.3%), and clinical success in 73 (89%). No patient was lost to follow-up; 45 patients (54.9%) completed 1-year follow-up with in situ LAMS. Median (interquartile range) LAMS indwell time was 364 (47-367) days. Overall, 12 (14.6%) patients presented 14 AEs, including 5 (6.1%) recurrent biliary events (3 acute cholangitis, 1 mild acute pancreatitis, and 1 acute cholecystitis). Patients with pancreatobiliary malignancy had an increased risk of recurrent biliary events (33% vs 1.5%, P = 0.001). The overall 1-year cumulative risk of recurrent biliary events was 9.7% (4.1-21.8%). The 1-year risk of AEs and of severe AEs was 18.8% (11-31.2%) and 7.9% (3.3-18.2%), respectively. Pancreatobiliary malignancy was the single risk factor for recurrent biliary events; LAMS misdeployment was the strongest risk factor for AEs.

CONCLUSIONS

Long-term LAMS indwell does not increase the risk of delayed AEs following EUS-GBD.

EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video)

BACKGROUND AND AIMS

Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV.

METHODS

This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events.

RESULTS

A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers.

CONCLUSIONS

This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

Predictive models in EUS/ERCP

Predictive models (PMs) in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) have the potential to improve patient outcomes, enhance diagnostic accuracy, and guide therapeutic interventions. This review aims to summarize the current state of predictive models in ERCP and EUS and their clinical implications. To be considered useful in clinical practice a PM should be accurate, easy to perform, and may consider objective variables. PMs in ERCP estimate correct indication, probability of success, and the risk of developing adverse events. These models incorporate patient-related factors and technical aspects of the procedure. In the field of EUS, these models utilize clinical and imaging data to predict the likelihood of malignancy, presence of specific lesions, or risk of complications related to therapeutic interventions. Further research, validation, and refinement are necessary to maximize the utility and impact of these models in routine clinical practice.

[Effectiveness and safety of endosonography-guided liver biopsy in liver disease at a level III public hospital]

Parenchymal liver diseases are commonly evaluated by laboratory and imaging studies. However, in some cases a liver biopsy is required. Endoscopic ultrasonography-guided liver biopsy (EUS-LB) has been reported as a procedure with high diagnostic yield (90-100%) with low adverse event profile, but there are not studies which report about the experience and technique in our country.

OBJECTIVE

Determinate the effectiveness and the safety of endosonography-guided liver biopsy in liver parenchymal disease.

MATERIALS AND METHODS

A prospective study was conducted at a III-2 level of care Public Hospital in Lima, Peru. It included patients over 18 years of age with suspicion of parenchymal liver disease who underwent EUS-LB for study hepatic parenchymal disease since March of 2018 to October of 2022.

RESULTS

The diagnostic yield of the biopsies was 77.02%, with a mean length of the sample of 13.98mm (standard deviation 7.34) and a median of 8 complete portal spaces (0-50). Only 31.25% of the procedures were performed with a fine needle biopsy (FNB), finding a significant difference between the type of needle and the diagnostic yield (p=0.01). The most common histopathological diagnosis was autoinmune hepatitis. There were 2.08% of post-procedure complications.

CONCLUSIONS

EUS-LB for the diagnosis of liver parenchymal disease had a diagnostic yield close to 80% in our region with a low profile of adverse events. However, more prospectives studies with a larger number of patients are required.

Adverse events with EUS-guided biliary drainage: a systematic review and meta-analysis

BACKGROUND AND AIMS

Multiple meta-analyses have evaluated the technical and clinical success of EUS-guided biliary drainage (BD), but meta-analyses concerning adverse events (AEs) are limited. The present meta-analysis analyzed AEs associated with various types of EUS-BD.

METHODS

A literature search of MEDLINE, Embase, and Scopus was conducted from 2005 to September 2022 for studies analyzing the outcome of EUS-BD. The primary outcomes were incidence of overall AEs, major AEs, procedure-related mortality, and reintervention. The event rates were pooled using a random-effects model.

RESULTS

One hundred fifty-five studies (7887 patients) were included in the final analysis. The pooled clinical success rates and incidence of AEs with EUS-BD were 95% (95% confidence interval [CI], 94.1-95.9) and 13.7% (95% CI, 12.3-15.0), respectively. Among early AEs, bile leak was the most common followed by cholangitis with pooled incidences of 2.2% (95% CI, 1.8-2.7) and 1.0% (95% CI, .8-1.3), respectively. The pooled incidences of major AEs and procedure-related mortality with EUS-BD were .6% (95% CI, .3-.9) and .1% (95% CI, .0-.4), respectively. The pooled incidences of delayed migration and stent occlusion were 1.7% (95% CI, 1.1-2.3) and 11.0% (95% CI, 9.3-12.8), respectively. The pooled event rate for reintervention (for stent migration or occlusion) after EUS-BD was 16.2% (95% CI, 14.0-18.3; I2 = 77.5%).

CONCLUSIONS

Despite a high clinical success rate, EUS-BD may be associated with AEs in one-seventh of the cases. However, major AEs and mortality incidence remain less than 1%, which is reassuring.

Immunotherapy for the elderly. Maybe the best option for lung cancer?

Lung cancer is usually diagnosed at advanced stage and systematic therapy is administered. New current diagnostic techniques such as the convex-endobronchial ultrasound, radial endobronchial ultrasound, cone beam ct, electromagnetic navigation and robotic bronchoscopy provide us with a high diagnostic yield. These techniques are minimal invasive and patients with comorbidities such as chronic obstructive pulmonary disease and heart failure can be diagnosed with minimal adverse effects. All these techniques provide sufficient sample for molecular investigation. Since immunotherapy was first administered, we have more and more information regarding the appropriate patient target group. Several published studies divided patients as elderly ≥75 and non-elderly ≤74 and investigated the adverse effects of different drugs and survival. In our current commentary we present information on patients receiving immunotherapy versus chemoimmunotherapy in two groups of elderly and non-elderly. Elderly patients can receive both combinations without differences between the two groups, however; more studies are needed to clarify certain aspects.

Drainage of Afferent Limb Obstruction via the Trans-gastric-bile Duct Formed after Endoscopic Ultrasound-guided Hepaticogastrostomy in a Patient with Pancreatic Cancer

A 63-year-old man with advanced pancreatic cancer and pyloric obstruction underwent surgical gastrojejunostomy. Malignant biliary obstruction appeared eight months after surgery and was managed with endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS). Subsequently, afferent limb obstruction caused by cancer invasion occurred. Although an intestinal metal stent could not be placed, a biliary metal stent was deployed via the HGS route, which successfully decompressed the afferent limb; the abdominal symptoms subsequently disappeared. In future similar cases, decompression of the dilated intestine through the HGS and biliary stent might be a viable treatment option.

Endoscopic Ultrasound-guided Versus Percutaneous Transhepatic Biliary Drainage After Failed ERCP: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may fail to achieve biliary drainage in 5% to 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and percutaneous transhepatic biliary drainage (PTBD) are alternative therapeutic options in such cases. The present meta-analysis aimed to compare the efficacy and safety of EUS-BD and PTBD for biliary decompression after failed ERCP.

METHODS

A comprehensive search of literature from inception to September 2022 was done of 3 databases for studies comparing EUS-BD and PTBD for biliary drainage after failed ERCP. Odds ratios (ORs) with 95% CIs were calculated for all the dichotomous outcomes. Continuous variables were analyzed using mean difference (MD).

RESULTS

A total of 24 studies were included in the final analysis. Technical success was comparable between EUS-BD and PTBD (OR=1.12, 0.67-1.88). EUS-BD was associated with a higher clinical success rate (OR=2.55, 1.63-4.56) and lower odds of adverse events (OR=0.41, 0.29-0.59) compared with PTBD. The incidence of major adverse events (OR=0.66, 0.31-1.42) and procedure-related mortality (OR=0.43, 0.17-1.11) were similar between the groups. EUS-BD was associated with lower odds of reintervention with an OR of 0.20 (0.10-0.38). The duration of hospitalization (MD: -4.89, -7.73 to -2.05) and total treatment cost (MD: -1355.46, -2029.75 to -681.17) were significantly lower with EUS-BD.

CONCLUSIONS

EUS-BD may be preferred over PTBD in patients with biliary obstruction after failed ERCP where appropriate expertise is available. Further trials are required to validate the findings of the study.

Diagnostic performance and safety of endoscopic ultrasound-guided tissue acquisition of gallbladder lesions: A systematic review with meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of the present meta-analysis was to assess the pooled adequacy, accuracy and safety of EUS-TA of GB lesions.

METHODS

A literature search from January 2000 to August 2022 was done for studies analyzing the outcome of EUS-guided TA in patients with GB lesions. Pooled event rates were expressed with summative statistics.

RESULTS

The pooled rate of sample adequacy for all GB lesions and malignant GB lesions was 97.0% (95% CI: 94.5-99.4) and 96.6% (95% CI: 93.8-99.3), respectively. The pooled sensitivity and specificity for the diagnosis of malignant lesions were 90% (95% CI: 85-94; I2 = 0.0%) and 100% (95% CI: 86-100; I2 = 0.0%), respectively, with an area under the curve of 0.915. EUS-guided TA had a pooled diagnostic accuracy rate of 94.6% (95% CI: 90.5-96.6) for all GB lesions and 94.1% (95% CI: 91.0-97.2) for malignant GB lesions. There were six reported mild adverse events (acute cholecystitis = 1, self-limited bleeding = 2, self-limited episode of pain = 3) with a pooled incidence of 1.8% (95% CI: 0.0-3.8) and none of the patients had serious adverse events.

CONCLUSION

EUS-guided tissue acquisition from GB lesions is a safe technique with high sample adequacy and diagnostic accuracy. EUS-TA can be an alternative when traditional sampling techniques fail or are not feasible.

Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management

BACKGROUND

The introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.

AIM

To evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.

METHODS

We conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms “lumen apposing metal stent”, “LAMS”, “endoscopic ultrasound” and “choledochoduodenostomy” or “gallbladder” or “pancreatic fluid collections”. We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.

RESULTS

The overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.

CONCLUSION

LAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise. In this review, we investigated the misdeployment of LAMS for each of the on-label indications focusing on the rescue therapies used, with the aim of providing useful data for endoscopists and to improve patient outcomes.

Prophylactic EUS-guided gallbladder drainage prevents acute cholecystitis in patients with malignant biliary obstruction and cystic duct orifice involvement: a randomized trial (with video)

BACKGROUND AND AIMS

Patients with distal malignant biliary obstruction (MBO) and cystic duct orifice tumoral involvement have an increased risk for the development of acute cholecystitis after self-expandable metallic stent (SEMS) placement. We aimed to determine whether primary EUS-guided gallbladder drainage prevents acute cholecystitis in these patients.

METHODS

This was a single-center, randomized control trial in patients with distal MBO enrolled from July 2018 to July 2020. Patients were randomized into 2 groups: an interventional group treated with conventional ERCP biliary drainage with SEMS placement and subsequent primary EUS-guided gallbladder drainage (EUS-GBD) and a control group treated with conventional biliary drainage alone. The primary outcome of the study was the occurrence of post-treatment acute cholecystitis, assessed for ≤12 months or until death. The secondary outcomes were hospitalization length and median survival time.

RESULTS

Forty-four patients were included in the study: 22 in each group. Five patients in the control group (22.7%) and none in the intervention group experienced acute cholecystitis. The median hospitalization time was significantly lower in the interventional group than in the control group (2 days vs 1 day, P = .017). There was no difference in the observed median survival rates in the primary EUS-GBD group (2.9 months) and the control group (2.8 months) (P = .580).

CONCLUSION

In this single-center study of patients with unresectable MBO and occlusion of the cystic duct orifice, prophylactic EUS-GBD demonstrated a reduced incidence of acute cholecystitis.

Endoscopic Ultrasound Gastro-Enteroanastomosis for Benign Gastric Outlet Obstruction due to Large Duodenal Diverticula

Gastric outlet obstruction is a condition characterized by inadequate gastric emptying due to benign or malignant conditions inducing an inadequate oral intake. In recent years, a novel therapeutic treatment for this condition is given by the use of electrocautery lumen-apposing metal stents. In this case report, we want to present an example of a benign condition treated by endoscopic ultrasound-guided gastroenterostomy with the bi-flanged SpaxusTM stent (Taewoong Medical Co.) mounted on electrocautery catheter.

Long-term outcomes and predictors of adverse events of EUS-guided hepatico-gastrostomy for malignant biliary obstruction: Multicenter, retrospective study

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) may be a feasible and useful alternative in patients with malignant biliary obstruction (MBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). To date, the risk factors for adverse events (AEs) and long-term outcomes of EUS-HGS have not been fully explored according to stent type. Therefore, we evaluated potential risk factors for AEs and long-term outcomes of EUS-HGS.

METHODS

In total, 120 patients who underwent EUS-HGS were retrospectively reviewed. A multivariate analysis through Cox proportional hazard and logistic regression model was used to identify the risk factors for stent dysfunction and AEs, respectively. Stent patency and patient survival were evaluated using Kaplan-Meier plots with a log-rank test for each stent.

RESULTS

The technical and clinical success rates were 96.2% (102/106) and 83.0% (88/106). The median duration of stent patency was longer in self-expandable metal stents (SEMS) compared to plastic stents (PS) (158 vs. 108 days). Kaplan-Meier analysis indicated that the type of stent was not associated with stent patency (Hazard ratios [HR] 0.997, 95% confidence interval [CI] [0.525-1.896]) or overall survival. In addition, multivariate analysis indicated that hilar MBO significantly associated with stent dysfunction (HR, 2.340; 95% CI, 1.028-5.326, p = 0.043) and late AEs.

CONCLUSIONS

Given the lower incidence of AEs and better long-term outcomes of EUS-HGS, it can be considered a safe alternative to ERCP or percutaneous approaches regardless of which stent is used. Furthermore, hilar MBO was established as a potential risk factor for stent dysfunction and late AEs.

Endosonography-Guided Versus Percutaneous Gallbladder Drainage Versus Cholecystectomy in Fragile Patients with Acute Cholecystitis-A High-Volume Center Study

Background and Objectives: Acute cholecystitis is a frequent cause of admission to the emergency department, especially in old and frail patients. Percutaneous drainage (PT-GBD) and endosonographic guided drainage (EUS-GBD) could be an alternative option for relieving symptoms or act as a definitive treatment instead of a laparoscopic or open cholecystectomy (LC, OC). The aim of the present study was to compare different treatment groups. Materials and Methods: This is a five-year monocentric retrospective study including patients ≥65 years old who underwent an urgent operative procedure. A descriptive analysis was conducted comparing all treatment groups. A propensity score was estimated based on the ACS score, incorporated into a predictive model, and tested by recursive partitioning analysis. Results: 163 patients were included: 106 underwent a cholecystectomy (81 laparoscopic (LC) and 25 Open (OC)), 33 a PT-GBD and 21 EUS-GBD. The sample was categorized into three prognostic groups according to the adverse event occurrence rate. All patients treated with EUS-GBD or LC resulted in the low risk group, and the adverse event rate (AE) was 10/96 (10.4%). The AE was 4/28 (14.2%) and 21/36 (58.3%) in the middle- and high-risk groups respectively (p < 0.001). These groups included all the patients who underwent an OC or a PT-GBD. The PT-GBD group had a lower clinical success rate (55.5%) and higher RR (16,6%) when compared with other groups. Conclusions: Surgery still represents the gold standard for AC treatment. Nevertheless, EUS-GBD is a good alternative to PT-GBD in terms of clinical success, RR and AEs in all kinds of patients.

Single balloon enteroscopy-guided endoscopic retrograde pancreatography for the treatment of a symptomatic pancreatic pseudocyst complicated by pancreaticojejunostomy stricture: A case report

RATIONALE

Endoscopic treatment of a pancreatic pseudocyst complicated by pancreaticojejunostomy (PJ) stricture is challenging.

PATIENT CONCERNS

A 76-year-old woman presented with worsening abdominal pain and dyspepsia. She had been receiving adjuvant chemotherapy (capecitabine and cisplatin) for 4 months after pylorus-preserving pancreaticoduodenectomy (PPPD) for the treatment of extrahepatic cholangiocarcinoma.

DIAGNOSES

Laboratory findings included elevated serum amylase (145 U/L) and lipase (437 U/L) levels. Abdominal computed tomography (CT) showed a pancreatic pseudocyst of approximately 3 cm in size and pancreatic duct dilatation in the remnant pancreas. According to the Response Evaluation Criteria in Solid Tumors, cholangiocarcinoma is a stable disease.

INTERVENTIONS AND OUTCOMES

Endoscopic drainage of the pancreatic pseudocyst was planned. Single-balloon enteroscopy (SBE)-guided endoscopic retrograde pancreatography (ERP) with endoscopic ultrasonography (EUS) using a mini probe demonstrated a membranous PJ stricture and a pancreatic pseudocyst. Endoscopic pseudocyst drainage using a 7-Fr plastic stent was successfully performed after needle-knife incision of the PJ stricture. Follow-up abdominal CT after 3 weeks showed complete resolution of the pseudocyst. Chemotherapy was resumed.

LESSONS

SBE-guided ERP with EUS using a mini probe may be an effective and safe treatment in a patient with a pancreatic pseudocyst complicated by membranous PJ stricture after PPPD.

Percutaneous transhepatic cholangiography vs endoscopic ultrasound-guided biliary drainage: A systematic review

BACKGROUND

Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree, followed by the immediate insertion of a catheter. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.

AIM

To compare the technical aspects and outcomes of percutaneous transhepatic BD (PTBD) and EUS-BD.

METHODS

Different databases, including PubMed, Embase, clinicaltrials.gov, the Cochrane library, Scopus, and Google Scholar, were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.

RESULTS

Among the six studies that fulfilled the inclusion criteria, PTBD patients underwent significantly more reinterventions (4.9 vs 1.3), experienced more postprocedural pain (4.1 vs 1.9), and experienced more late adverse events (53.8% vs 6.6%) than EUS-BD patients. There was a significant reduction in the total bilirubin levels in both the groups (16.4-3.3 μmol/L and 17.2-3.8 μmol/L for EUS-BD and PTBD, respectively; P = 0.002) at the 7-d follow-up. There were no significant differences observed in the complication rates between PTBD and EUS-BD (3.3 vs 3.8). PTBD was associated with a higher adverse event rate than EUS-BD in all the procedures, including reinterventions (80.4% vs 15.7%, respectively) and a higher index procedure (39.2% vs 18.2%, respectively).

CONCLUSION

The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD. These findings highlight the evidence for successful EUS-BD implementation.

Transesophageal endoscopic ultrasound in the diagnosis of the lung masses: a multicenter experience with fine-needle aspiration and fine-needle biopsy needles

BACKGROUND AND AIM

Intraparenchymal lung masses inaccessible through bronchoscopy or endobronchial ultrasound guidance pose a diagnostic challenge. Furthermore, some fragile or hypoxic patients may be poor candidates for transbronchial approaches. Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) offers a potential diagnostic approach to lung cancers adjacent to the esophagus. We aimed to evaluate the feasibility, accuracy, and safety of trans-esophageal EUS-FNA/FNB for tissue sampling of pulmonary nodules.

METHODS

We retrospectively analyzed data from patients with pulmonary lesions who underwent EUS-FNA/FNB between March 2015 and August 2021 at eight Italian endoscopic referral centers.

RESULTS

A total of 47 patients (36 male; mean age 64.47 ± 9.05 years) were included (22 EUS-FNAs and 25 EUS-FNBs). Overall diagnostic accuracy rate was 88.9% (76.3-96.2%). The sensitivity and diagnostic accuracy were superior for EUS FNB sampling versus EUS-FNA (100% vs. 78.73%); P = 0.05, and (100% vs. 78.57%); P = 0.05, respectively. Additionally, sample adequacy was superior for EUS-FNB sampling versus EUS-FNA (100% vs. 78.5%); P = 0.05. Multivariate logistic regression analysis for diagnostic accuracy showed nodule size at the cutoff of 15 mm (OR 2.29, 1.04-5.5, P = 0.05) and use of FNB needle (OR 4.33, 1.05-6.31, P = 0.05) as significant predictors of higher diagnostic accuracy. There were no procedure-related adverse events.

CONCLUSION

This study highlights the efficacy and safety of EUS-FNA/FNB as a minimally invasive procedure for diagnosing and staging peri-esophageal parenchymal lung lesions. The diagnostic yield of EUS-FNB was superior to EUS-FNA.

Efficacy, Feasibility, and Safety of Endoscopic Ultrasound-guided Fine-needle Biopsy for the Diagnosis of Gastrointestinal Subepithelial Lesions: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS) fine-needle biopsy (FNB) has become an efficient method for diagnosing gastrointestinal (GI) subepithelial lesions (SELs). However, recent guidelines have not regarded FNB as the primary strategy for diagnosing GI SELs. We performed this study to systematically measure the efficacy, feasibility, and safety of EUS-FNB in diagnosing GI SELs.

MATERIALS AND METHODS

Relevant studies were searched in PubMed and EMBASE and published after January 2015 were included. The overall rates of diagnostic yield, technical success, and adverse events were calculated as outcome measures. The Jadad scale and the Newcastle-Ottawa scale were used to evaluate the quality of the trials, funnel plots and Egger's test were used to measure publication bias, and sensitivity and subgroup analyses were performed to explore the variance of heterogeneity and sensitivity, respectively.

RESULTS

Sixteen studies analyzing 969 patients between 2015 and 2020 were included. Studies showed little change in sensitivity, and 13 were considered high quality. A certain degree of publication bias existed in the diagnostic accuracy rate. The overall rates of diagnostic yield, technical success, and adverse events were [85.69% (95% confidence interval (CI): 82.73-88.22, I2=41.8%), 98.83% (95% CI: 96.73-99.97, I2=54.3%), and 1.26% (95% CI: 0.35-2.54, I2=0.0%)]. No clinical influencing factors were identified in the subgroup analysis.

CONCLUSIONS

EUS-FNB is a promising technology with a relatively superior diagnostic yield, technical success, and security, which is an optimal option for the diagnosis of SELs.

Endoscopic Ultrasonography-guided Gastrojejunostomy for Patients with Gastric Outlet Obstruction and Pyloric Metal Stent Dysfunction

A 52-year-old woman with a gastric outlet obstruction (GOO) caused by pyloric cancer underwent pyloric endoscopic self-expandable metal stent (SEMS) insertion. She presented with abdominal distension 40 days later. The SEMS was dysfunctional, and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) was performed using an endoscopic nasobiliary drainage tube. A 16 mm×31 mm Niti-S ™ HOT SPAXUS™ (TaeWoong Medical, Gimpo, Korea) was inserted successfully between the stomach and the adjacent jejunum. After the procedure, the patient had a good oral intake for more than seven months. GOO is a mechanical obstructive condition caused by various benign and malignant conditions. Traditionally, surgical GJ and SEMS insertion have been used to treat GOOs. EUS-GJ is a feasible treatment option for patients with GOO and a pyloric metal stent dysfunction.

Efficacy and Safety of Endobronchial Ultrasonography with a Guide-sheath for Acute Pulmonary Lesions in Patients with Haematological Diseases

Objective Acute pulmonary lesions (APLs), defined as an acute infiltrate or nodular lung field, are a major complication in patients with haematological diseases. Recently, endobronchial ultrasonography with a guide-sheath (EBUS-GS) was established as a useful technique for diagnosing pulmonary lesions. This study aimed to evaluate the efficacy and safety of EBUS-GS for managing APLs in patients with haematological diseases. Methods Our single-centre, retrospective, observational, single-arm, descriptive study enrolled 22 consecutive adult (>20-year-old) patients with haematological diseases and concomitant APL who underwent EBUS-GS between January 2011 and June 2016 at Kameda Medical Center, Chiba, Japan. The primary endpoint was the contribution of EBUS-GS to clinical decision-making. Secondary endpoints were an adequate tissue collection rate, diagnostic yield, complication rate, and 30-day mortality. Results The median patient age was 70 years old, and 63.6% were men. Acute myeloid leukaemia was the most frequent underlying disease, accounting for 54.5% of patients. The contribution of EBUS-GS to clinical decision-making was recognised in 11 (50.0%) patients. Adequate tissue collection was achieved in 21 (95.5%) patients. The aetiology of the APL was identified in 9 (40.9%) patients. No complications, including severe haemorrhaging and pneumothorax, were observed in any patients, and the 30-day mortality rate was 0%. Conclusion EBUS-GS may be a suitable diagnostic option for APL in patients with haematological diseases. Further larger-scale and randomised controlled trials are needed to confirm our results.

EUS-CGN versus EUS-CPN in pancreatic cancer: A qualitative systematic review

BACKGROUND

Comparison between endosonographic ultrasonography (EUS)-guided celiac ganglia neurolysis (CGN) and EUS-guided celiac plexus neurolysis (CPN) in pain management for pancreatic cancer has engendered controversy. To analyze the effectiveness and safety of EUS-CGN and figure out whether EUS-CGN is better than EUS-CPN, a qualitative systematic review was conducted.

METHODS

Studies were searched from Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE up to April 2020. We only included studies with full-text and in English and assessed study quality with Newcastle-Ottawa Scale or Cochrane risk-of-bias tool. We recorded details of study design, participants, procedure performed, protocol of follow-up, pain response, quality of life, survival, and adverse events. The study was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2009.

RESULTS

Five studies involving 319 patients were included. Short-term pain response rates ranged from 65.0% to 88.46% in EUS-CGN group and most studies reported its superiority over EUS-CPN. As for adverse events, the incidence of transient hypotension and gastrointestinal symptoms seemed comparable, while results of initial pain exacerbation varied among studies. Besides, EUS-CGN might provide a shorter survival.

CONCLUSION

EUS-CGN can be safely performed while it may shorten survival. In terms of short-term pain response, EUS-CGN is better than EUS-CPN while no conclusion of long-term pain control can be drawn.

Endoscopic drainage for management of infected necrosis following EUS-TA in a patient with pancreatic cancer: A case report

RATIONALE

Endoscopic ultrasonography-guided tissue acquisition (EUS-TA) has become the norm for the diagnosis of pancreatic solid lesions. EUS-TA is relatively safe, but various complications can occur. Infected pancreatic necrosis (IPN) is a rare but serious complication. The latest guidelines suggest that all invasive interventions in patients with IPN should be delayed until walled-off necrosis appears.

PATIENT CONCERNS

A 73-year-old man was referred to our hospital with double primary cancers including gallbladder and pancreas. We performed EUS-TA on metastatic pancreatic tail cancer to confirm histologic diagnosis. Six days after the procedure, he developed abdominal pain and fever.

DIAGNOSES

The patient's laboratory findings showed leukocytosis and C-reactive protein elevation. Fluid collection around pancreas tail and stomach was detected in computed tomography (CT) scan, and the patient was diagnosed with IPN.

INTERVENTIONS AND OUTCOMES

EUS-guided endoscopic transmural drainage (EUS-TD) was performed for the treatment of IPN. Two days after the procedure with antibiotics, his CRP level decreased abruptly, and he received chemotherapy for the treatment of pancreatic ductal adenocarcinoma (PDAC) 5 days after the procedure. He was discharged from our hospital without complications 15 days after chemotherapy.

LESSONS

In selected patients with PDAC, early endoscopic drainage may be recommended as treatment for IPN resulting from complications of EUS-TA.

Unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe endobronchial ultrasound

BACKGROUND

Bronchoscopy using radial probe endobronchial ultrasound (EBUS) is performed when a peripheral lung lesion (PLL) is suspected to be malignant. However, pulmonary tuberculosis is diagnosed in some patients, and healthcare workers could therefore be exposed to tuberculosis if sufficient precautions are not taken. In this study, we examined the proportion of and factors associated with unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe EBUS.

METHODS

This retrospective study included 970 patients who received bronchoscopy using radial probe EBUS between December 2015 and November 2018. Clinical, histological, radiological, and microbiological data were reviewed.

RESULTS

Pulmonary tuberculosis was diagnosed in 31 patients (3.2%) during bronchoscopy using radial probe EBUS. Patients with a lower age were significantly more likely to be diagnosed with tuberculosis than elderly patients (odds ratio [OR], 0.951; 95% confidence interval [CI], 0.924-0.978; P = 0.001). Among the various CT findings, a low HUs difference between pre- and post-enhanced CT (OR, 0.976; 95% CI, 0.955-0.996; P = 0.022), the presence of concentric cavitation (OR, 5.211; 95% CI, 1.447-18.759; P = 0.012), and the presence of satellite centrilobular nodules (OR, 22.925; 95% CI, 10.556-49.785; P < 0.001) were independently associated with diagnosis of tuberculosis.

CONCLUSIONS

The proportion of unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe EBUS was 3.2%. A higher risk was independently associated with a younger age and CT findings of a small difference in HUs between pre- and post-enhancement images, concentric cavitation, and the presence of a satellite centrilobular nodule.

Duodenoscope as a Vector for Transmission

Elevator-based endoscope-related infections from patient cross-contamination is a multifactorial problem related to device design, maintenance, and function, with additional risk incurred from a high-level disinfection process that lacks quality controls. This article reviews the historical context for these outbreaks, technical aspects of scope design contributing to this risk, and innovations in endoscope technology that have the potential to overcome these shortcomings. Also reviewed are interim solutions and the data that support use of some of these interventions. Still needed are a validated manufacturer-recommended schedule for routine duodenoscope and echoendoscope maintenance with reprocessing protocols that can be implemented in endoscopy units.

Endosonographic finding of the simultaneous depiction of bile and pancreatic ducts can predict difficult biliary cannulation on endoscopic retrograde cholangiopancreatography

Thus far, no curved linear array endoscopic ultrasound (CLAEUS) findings were established as predictors of difficult selective bile duct cannulation (SBDC). This study aimed to identify CLAEUS findings to predict endoscopic retrograde cholangiopancreatography (ERCP) cases with difficult SBDC. This single-center, retrospective cohort study was conducted between July 2014 and June 2017. This study included all consecutive patients who underwent CLAEUS prior to naïve ERCP. A CLAEUS finding of the simultaneous depiction of bile and pancreatic ducts at the second portion of the duodenum (D2) (simultaneous depiction) was selected as a possible predictor of difficult SBDC, and the κ values in the evaluation of inter- and intra-observer variabilities for “simultaneous depiction” were 0.65 and 0.77, respectively, with substantial correlation. Among the 986 patients who underwent ERCP, 80 patients were relevant for evaluation. Logistic regression analysis revealed strong association between “simultaneous depiction” and difficult SBDC (odds ratio 15.4, 95% confidence interval 4.2–56.0; p<0.001). Among patients who underwent CLAEUS prior to naïve ERCP, a strong correlation was observed between “simultaneous depiction” and the risk of difficult SBDC. An endoscopist can prepare for difficult SBDC by “simultaneous depiction.” The finding enables pertinent planning when performing ERCP, such as setting time limits and selecting alternative devices, techniques, and skilled endoscopists, for difficult SBDC with minimal complications including post-ERCP pancreatitis. However, a future prospective study is necessary to establish the procedure algorithm for suspected difficult SBDC cases based on CLAEUS.

[Efficacy and safety of echoendoscopy drainage of liquid peripancreatic collections in a reference hospital]

INTRODUCTION

Endoscopic ultrasound (EUS) guided drainage is considered the best option for peripancreatic fluid collections drainage. There are no previous reports in our country of this type of endoscopic therapy.

OBJECTIVES

To detail the characteristics, efficacy and safety of EUS-guided drainage of peripancreatic fluid collections at Edgardo Rebagliati Martins National Hospital.

MATERIALS AND METHODS

We carried out a retrospective cross-sectional study of all patients who underwent EUS-guided drainage of symptomatic peripancreatic fluid collections. Demographics, procedure-related endosonographic features and devices used were analyzed. We assessed the effectiveness with technical and clinical success rate. Clinical safety was assessed based on major immediate and delayed adverse events. Basic descriptive statistics was used.

RESULTS

A total of 17 patients (9 women, 52.9% and 8 men, 47.1%) with peripancreatic fluid collections (10 pseudocysts and 7 walled-off necrosis) underwent EUS-guided drainage. The median age of the patients was 59 years (range 26 - 72 years). The mean diameter of the fluid collections was 14.8 cm (range 8-24 cm). Transgastric route was used in 16 cases (94.1%) and transduodenal route in 1 case (5.9%). Plastic stent (6 cases), biliary self expanding metal stent (4 cases) and lumen apposing stent (7 cases) were used. The technical success rate was 100% (17 patients), while clinical success rate was 70.6% (12 patients). Adverse events occurred in 41.2%: infection (2 cases), perforation, bleeding, plastic stent occlusion, stent migration into the collection cavity and out of the collection cavity (1 case each one). Surgical management of adverse events was necessary in 3 cases, while the 4 other cases only required medical - endoscopic management.

CONCLUSIONS

EUS-guided drainage of peripancreatic fluid collections have a high technical and clinical success rate with a low percentage of adverse events.

Efficacy of the Endoscopic Ultrasound-first Approach in Patients with Suspected Common Bile Duct Stone to Avoid Unnecessary Endoscopic Retrograde Cholangiopancreatography

Objective Endoscopic ultrasound (EUS) is a safe and accurate examination for evaluating the presence of common bile duct stones (CBDSs). The EUS-first approach, where EUS is performed before endoscopic retrograde cholangiopancreatography (ERCP) for patients suspected of having CBDSs, may help reduce the risk of ERCP-related adverse events and save manpower by avoiding unnecessary ERCP. To evaluate the efficacy of the EUS-first approach in patients with suspected CBDSs. Methods Between April 2012 and March 2016, 104 patients who underwent the EUS-first approach for suspected CBDSs were retrospectively evaluated. The relevant outcomes were the short- and long-term adverse event rates and the ERCP avoidance rate. Results EUS findings were positive for CBDSs in 52 patients, showed sludge formation or possible CBDSs in 4 patients, and were negative for CBDSs in 42 patients (but positive for other diseases in 6). Sixty-two patients (62/104, 59.6%) underwent ERCP, and proper treatments were successfully performed in all but 1 who underwent only cholangiography. In the remaining 42 patients (42/104, 40.4%), ERCP was omitted based on the EUS findings. Early adverse events were recognized in 0% of the EUS-only group and 8 patients (12.9%) in the EUS+ERCP group (p=0.02). Regarding late adverse events, recurrent CBDSs occurred in 1 patient (2.3%) in the EUS-only group and 2 (3.2%) in the EUS+ERCP group (p=1.0). Conclusion The EUS-first approach in patients with suspected CBDSs was useful for reducing early adverse events associated with ERCP without increasing the late adverse event rate, as EUS enabled the avoidance of unnecessary ERCP.

Prospective assessment of the effectiveness of standard high-level disinfection for echoendoscopes

BACKGROUND AND AIMS

Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDROs). Echoendoscopes could potentially transmit infection. The aim of this study was to assess the effectiveness of standard high-level disinfection (HLD) for radial and linear echoendoscopes and to compare it with that of duodenoscopes.

METHODS

We performed a prospective single-center study sampling echoendoscopes immediately before use, from the working channel (radial and linear echoendoscopes) and the transducer (radial echoendoscope) or elevator mechanism and transducer (linear echoendoscope). The primary outcome was the proportion of echoendoscopes with any culture showing ≥1 MDRO; secondary outcomes included bacterial growth >0 colony forming units (CFUs) and ≥10 CFUs on either sampling location. We compared these findings with duodenoscope cultures from the previously published DISINFECTS trial.

RESULTS

During the study period, 101 echoendoscopes were sampled (n = 50 radial echoendoscopes, n = 51 linear echoendoscopes). No MDROs were recovered. Bacterial growth >0 CFUs was noted in 6% and ≥10 CFUs in 3% of all echoendoscopes. There was no significant difference in growth between radial and linear echoendoscopes (P = .4 for >0 CFU growth; P = .6 for ≥10 CFUs growth). The proportion of transducer and/or elevator mechanism positive for bacterial growth was significantly higher in duodenoscopes as compared with echoendoscopes (P = .02).

CONCLUSIONS

After standard HLD, no echoendoscope showed MDRO growth, 6% showed >0 CFUs, and 3% showed ≥10 CFUs bacterial growth. Bacterial growth was higher in duodenoscopes at the level of the transducer and/or elevator mechanism when compared with echoendoscopes.

Endoscopy in inflammatory bowel disease: Role in diagnosis, management, and treatment

Endoscopy plays a fundamental role in the diagnosis, management, and treatment of inflammatory bowel disease (IBD). Colonoscopy, flexible sigmoidoscopy, and esophagogastroduodenoscopy have long been used in the care of patients with IBD. As endoscopic technologies have progressed, tools such as endoscopic ultrasound, capsule endoscopy, and balloon-assisted enteroscopy have expanded the role of endoscopy in IBD. Furthermore, chromoendoscopy has enhanced our ability to detect dysplasia in IBD. In this review article, we will focus on the roles, indications, and limitations of these tools in IBD. We will also discuss the most commonly used endoscopic scoring systems, as well as special considerations in post-surgical patients. Lastly, we will discuss the role of endoscopy in the diagnosis and management of fistulae and strictures.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

BACKGROUND AND AIMS

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this study were to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction.

METHODS

The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated.

RESULTS

Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P = 1.00, P = 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group.

CONCLUSIONS

This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

New horizons in the endoscopic ultrasonography-based diagnosis of pancreatic cystic lesions

Pancreatic cystic lesions (PCLs) are increasingly being identified because of the widespread use of high-resolution abdominal imaging. These cysts encompass a spectrum from malignant disease to benign lesions, and therefore, accurate diagnosis is crucial to determine the best management strategy, either surgical resection or surveillance. However, the current standard of diagnosis is not accurate enough due to limitations of imaging and tissue sampling techniques, which entail the risk of unnecessary burdensome surgery for benign lesions or missed opportunities of prophylactic surgery for potentially malignant PCLs. In the last decade, endoscopic innovations based on endoscopic ultrasonography (EUS) imaging have emerged, aiming to overcome the present limitations. These new EUS-based technologies are contrast harmonic EUS, needle-based confocal endomicroscopy, through-the-needle cystoscopy and through-the needle intracystic biopsy. Here, we present a comprehensive and critical review of these emerging endoscopic tools for the diagnosis of PCLs, with a special emphasis on feasibility, safety and diagnostic performance.

[Mediastinitis following EBUS : about a complication after a minimally invasive investigation]

Endobronchial ultrasound (EBUS) is a minimally invasive investigation method that permits transbronchial needle aspiration (TBNA) of mediastinal and hilar lymphadenopathies in order to determine their etiology. Its indications are notably lung cancer staging and lymphadenopathy exploration in case of sarcoidosis and malignant lymphomas. The employment of EBUS-TBNA has grown over the past few years and has become an alternative to mediastinoscopy due to a lower complication rate. However, in rare cases, complications can occur as hemorrhage, infections (mediastinitis, pneumonia, pericarditis, cyst infection, sepsis) or other (pneumothorax, pneumomediastinitis). We report herein a case of a mediastinitis after endobronchial ultrasound-guided transbronchial needle aspiration which occurred in a 63-year-old patient treated by methotrexate and methylprednisolone for a rheumatoid arthritis. The symptoms appeared as fever and progressive dyspnea some days after the endoscopic procedure.

Endoscopic ultrasound-guided transmural drainage for subphrenic abscess: report of two cases and a literature review

BACKGROUND

An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route.

CASE PRESENTATION

We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible.

CONCLUSIONS

Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

How the Experts Do It: Step-by-Step Guide

Lumen-apposing metal stents are integrated in a single-step delivery system for draining intra-abdominal fluid collections. The theoretic advantage of lumen-apposing stents is the ability to approximate the wall of the drained cavity or organ to the gastrointestinal tract lumen. The use of lumen-apposing stents now includes drainage of organs adjacent to the stomach/duodenum and creation of anastomosis between the stomach and jejunum. The lumen-apposing stents may also serve as a conduit for accessing the remnant stomach for performing biliary tract interventions. This article outlines the approach to placement of lumen-apposing metal stents, technical challenges, and measures to counter adverse events.

Short- and long-term results of endoscopic ultrasound-guided transmural drainage for pancreatic pseudocysts and walled-off necrosis

AIM

To evaluate the short- and long-term results of endoscopic ultrasound-guided transmural drainage (EUS-GTD) for pancreatic fluid collection (PFC) and identify the predictive factors of treatment outcome for walled-off necrosis (WON) managed by EUS-GTD alone.

METHODS

We investigated 103 consecutive patients with PFC who underwent EUS-GTD between September 1999 and August 2015. Patients were divided into four groups as follows: WON (n = 40), pancreatic pseudocyst (PPC; n = 11), chronic pseudocyst (n = 33), and others (n = 19). We evaluated the short- and long-term outcomes of the treatment. In cases of WON, multiple logistic regression analyses were performed to identify the predictor variables associated with the treatment success. In addition, PFC recurrence was examined in patients followed up for more than 6 mo and internal stent removal after successful EUS-GTD was confirmed.

RESULTS

In this study, the total technical success rate was 96.1%. The treatment success rate of WON, PPC, chronic pseudocyst, and others was 57.5%, 90.9%, 91.0%, and 89.5%, respectively. Contrast-enhanced computed tomography using the multivariate logistic regression analysis revealed that the treatment success rate of WON was significantly lower in patients with more than 50% pancreatic parenchymal necrosis (OR = 17.0; 95%CI: 1.9-150.7; P = 0.011) and in patients with more than 150 mm of PFC (OR = 27.9; 95%CI: 3.4-227.7; P = 0.002).The recurrence of PFC in the long term was 13.3% (median observation time, 38.8 mo). Mean amylase level in the cavity was significantly higher in the recurrence group than in the no recurrence group (P = 0.02).

CONCLUSION

The reduction of WON by EUS-GTD alone was associated with the proportion of necrotic tissue and extent of the cavity. The amylase level in the cavity may be a predictive factor for recurrence of PFC.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.

METHODS

We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.

RESULTS

We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.

CONCLUSION

We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Value of radial probe endobronchial ultrasound-guided transbronchial biopsy and computer tomography-guided transthoracic needle aspiration in the diagnosis of peripheral pulmonary lesions

Computer tomography-guided transthoracic needle aspiration (CT-TTNA) is a minimally invasive technique for sampling peripheral lung lesions. Radial endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) is an alternative. The present study analyzed and compared rEBUS-TBB and CT-TTNA in the diagnosis of peripheral pulmonary lesions (PPL).Clinical data of 513 patients with PPL who underwent an rEBUS-TBB or CT-TTNA examination were analyzed retrospectively. The positive diagnostic rate, complication rate, and influencing factors of the 2 methods were compared.The positive diagnostic rate and complication rate were significantly higher in CT-TTNA than rEBUS-TBB (P = .001; P < .001, respectively). The rEBUS-TBB group showed a higher positive diagnostic rate in larger lesions (>2 cm) than in smaller (≤2 cm) (P = .012), and was lower in the lesions proximal to the chest wall than those distally located (P = .046); no significant difference was observed in the different pulmonary segments (P = .109). In the CT-TTNA group, the positive diagnostic rate in larger lesions did not differ significantly than the smaller lesions (P = .05); it differed significantly in different segments (P = .044). The incidence of pneumothorax was lower in lesions proximal to the chest wall than those located distally (P = .037). In the rEBUS-TBB group, the success rate of the exploration and biopsy of the lesions was 87.4%; the rate of exploration of larger lesions and with bronchial sign was higher than smaller lesions and without bronchial sign (P < .001; P < .001, respectively) while that of lesions close to the chest wall was lower than those distally located (P = .006).rEBUS-TBB and CT-TTNA are effective and safe in the diagnosis of PPL. The positive diagnostic rate of CT-TTNA is higher than rEBUS-TBB. The incidence of pneumothorax in CT-TTNA is higher than rEBUS-TBB. CT-TTNA is selected for smaller lesions close to the chest wall; rEBUS-TBB is used for lesions larger, distal from the chest wall or with a bronchial sign.

Endoscopic ultrasound-guided radiofrequency ablation in gastroenterology: New horizons in search

Radiofrequency ablation (RFA) has been widely used for the treatment of various solid organ malignancies. Over the last decade, endosonographers have gradually shifted the application of RFA from porcine models to humans to treat a spectrum of diseases. RFA is performed in patients with pancreatic carcinoma who are not candidates for surgery. In this paper, we will discuss various indications for RFA, its procedural details and complications. At present, endoscopic ultrasound-guided RFA is gradually incorporated into the management of various diseases and opens a new avenue for disease treatment.

Endoscopic ultrasound sedation in the United Kingdom: Is life without propofol tolerable?

There is compelling evidence to support the quality, cost effectiveness and safety profile of non-anesthesiologist-administered propofol for endoscopic ultrasound (EUS). However in the United Kingdom, it is recommended that the administration and monitoring of propofol sedation for endoscopic procedures should be the responsibility of a dedicated and appropriately trained anaesthetist only. The majority of United Kingdom EUS procedures are performed with opiate and benzodiazepine sedation rather than anaesthetist led propofol lists due to anaesthetist resource availability. We sought to prospectively determine the tolerability and safety of EUS with benzodiazepine and opiate sedation in single United Kingdom centre. Two hundred consecutive patients undergoing either EUS or oesophago-gastroduodenoscopy (OGD) with conscious sedation were prospectively recruited with a 1:1 enrolment ratio. Patients completed questionnaires pre and post procedure detailing anticipated and actual pain experienced on a 1-10 visual analogue scale. Demographics, procedure duration, sedation doses and willingness to repeat the procedure were also recorded. EUS procedures lasted significantly longer than OGDs (15 min vs 6 min, P < 0.0001), however, there was no difference in anticipated pain scores between the groups (EUS 3.37/10 vs OGD 3.47/10, P = 0.46). Pain scores indicated EUS was better tolerated than OGD (1.16/10 vs 1.88/10, P = 0.03) although higher doses of sedation were used for EUS procedures. There were no complications identified in either group. We feel our study demonstrates that the tolerability of EUS with opiate and benzodiazepine sedation is acceptable.

[Anaphylaxis and allergic reactions during surgery and medical procedures]

Anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. It has an incidence of 1/10 000 to 1/20 000 surgeries. In most series, the responsible drugs include neuromuscular blocking agents, latex, or antibiotics. The frequency and etiology of systemic allergic reactions in other medical procedures are largely unknown. The identification of responsible drugs of anaphylaxis is a complex task, requiring testing of all medications and substances used during surgery. We describe our experience in a retrospective study of 15 patients. Ten subjects developed anaphylaxis during surgery, two in endoscopic studies and one in a trans-vaginal ultrasound. The remaining two subjects, one in a trans-vaginal ultrasound and another during a dental procedure had a systemic allergic reaction. We studied all patients with all medications administered during the procedures, including latex and detergents and disinfectants. Three surgeries had to be suspended at induction of anesthesia, five were stopped incomplete and two were completed. Both patients that presented a reaction during endoscopy required intensive care unit admission and the rest were observed in a Hospital. The responsible drugs during surgery anaphylaxis were neuromuscular blocking agents, latex, patent blue, and ranitidine. Ortho-phthalaldehyde (OPA) was identified during endoscopic studies; latex was responsible in transvaginal ultrasounds; and amoxicillin in the dental procedure. The aim of the present article is to review our experience studying allergic systemic reactions and anaphylaxis during general anesthesia and medical procedures, emphasizing the severity of these reactions and the need for causative drug identification.

Pain experience during saline-contrast sonohysterography differs between premenopausal and postmenopausal women

PURPOSE

To evaluate whether the pain experienced during and after Saline-contrast sonohysterography (SCSH) differs between premenopausal and postmenopausal women.

METHODS

Sonohysterography was performed on 133 consecutive women because of suspected endometrial pathology. Of these, 34 women were excluded for the following reasons: they had cervical stenosis; they did not complete or return a questionnaire; or tenaculum or cervical dilatators were used during the procedure. All women were asked to fill out a questionnaire to characterize their pain and mark their pain experience on a 100-mm pain visual analog scale.

RESULTS

Data from the 99 patients included were used for statistical analysis. It showed that sonohysterography was well tolerated overall: 41% of the women did not feel any pain. Postmenopausal women experienced pain during SCSH more often than premenopausal women did: 71% (17/24) compared with 32% (24/75) experienced pain; p < 0.002; the median tolerance on the 100-mm visual analog scale was 43. The character of the pain differed between the two groups of women: postmenopausal women more often felt sharp pain (42%; 10/24), whereas premenopausal women more often felt gnawing and/or crampy pain (21%; 16/75) (p < 0.13).

CONCLUSIONS

Postmenopausal women were twice as likely to experience pain during SCSH as premenopausal women were. Therefore, postmenopausal women might benefit from analgesia induced prior to the procedure. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:267-271, 2016.

Endoscopic ultrasonography-guided biliary drainage: Who, when, which, and how?

Both endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are relatively well established as alternatives to percutaneous transhepatic biliary drainage (PTBD). Both EUS-CDS and EUS-HGS have high technical and clinical success rates (more than 90%) in high-volume centers. Complications for both procedures remain high at 10%-30%. Procedures performed by endoscopists who have done fewer than 20 cases sometimes result in severe or fatal complications. When learning EUS-guided biliary drainage (EUS-BD), we recommend a mentor’s supervision during at least the first 20 cases. For inoperable malignant lower biliary obstruction, a skillful endoscopist should perform EUS-BD before EUS-guided rendezvous technique (EUS-RV) and PTBD. We should be select EUS-BD for patients having altered anatomy from malignant tumors before balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography, EUS-RV, and PTBD. If both EUS-CDS and EUS-HGS are available, we should select EUS-CDS, according to published data. EUS-BD will potentially become a first-line biliary drainage procedure in the near future.

Convex-probe Endobronchial Ultrasound: A Decade of Progress

Ever since the invention of the flexible bronchoscope, perhaps no other innovation in the field of interventional pulmonology has caused so much excitement the world over, as the convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). While it took over a decade from 1992 to 2004 for the radial EBUS to evolve into the commercial convex probe EBUS scope, another exciting decade has gone by with the technology being thoroughly researched and appraised. The current evidence suggests that EBUS-TBNA can replace mediastinoscopy as the first investigation in the mediastinal staging of lung cancer. The use of EBUS-TBNA has been extended to several other areas including the diagnosis of undefined mediastinal lymphadenopathy, evaluation of intra-parenchymal lesions and others. In fact, EBUS-TBNA is the preferred modality for accessing mediastinal lesions in contact with the airways. The procedure not only has a high diagnostic efficiency (80%-90% for most indications) but is also safe compared to alternative options, such as image-guided fine needle aspiration and mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Apart from the traditional use of EBUS to perform TBNA, the last decade has seen the evolution of its transoesophageal use, development of novel EBUS-TBNA needles to obtain better histological specimens and a smaller EBUS scope. This review summarises the developments made in this field over the years since its inception.