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   Table of Contents - Current issue
Coverpage
November-December 2018
Volume 7 | Issue 6
Page Nos. 353-423

Online since Thursday, December 6, 2018

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EDITORIAL  

EUS is trending! p. 353
Anand V Sahai
DOI:10.4103/eus.eus_22_18  PMID:30168481
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CONSENSUS Top

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction p. 356
Jintao Guo, Marc Giovannini, Anand V Sahai, Adrian Saftoiu, Christoph F Dietrich, Erwin Santo, Pietro Fusaroli, Ali A Siddiqui, Manoop S Bhutani, Anthony Yuen Bun Teoh, Atsushi Irisawa, Brenda Lucia Arturo Arias, Chalapathi Rao Achanta, Christian Jenssen, Dong-Wan Seo, Douglas G Adler, Evangelos Kalaitzakis, Everson Artifon, Fumihide Itokawa, Jan Werner Poley, Girish Mishra, Khek Yu Ho, Hsiu-Po Wang, Hussein Hassan Okasha, Jesse Lachter, Juan J Vila, Julio Iglesias-Garcia, Kenji Yamao, Kenjiro Yasuda, Kensuke Kubota, Laurent Palazzo, Luis Carlos Sabbagh, Malay Sharma, Mitsuhiro Kida, Mohamed El-Nady, Nam Q Nguyen, Peter Vilmann, Pramod Kumar Garg, Praveer Rai, Shuntaro Mukai, Silvia Carrara, Sreeram Parupudi, Subbaramiah Sridhar, Sundeep Lakhtakia, Surinder S Rana, Takeshi Ogura, Todd H Baron, Vinay Dhir, Siyu Sun
DOI:10.4103/eus.eus_53_18  PMID:30531022
Background and Objectives: EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed. Methods: This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD. Results: Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended. Conclusion: This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.
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REVIEW ARTICLES Top

Has the role of EUS in rectal cancer staging changed in the last decade? p. 366
Angad Singh Uberoi, Manoop S Bhutani
DOI:10.4103/eus.eus_36_18  PMID:30531023
The need for effective diagnosis, staging, and treatment of rectal cancer cannot be overstated. Accurate staging of rectal cancer has wide-ranging implications, including therapeutic strategy and prognosis. A change in stage may lead to the need for preoperative neoadjuvant therapy to decrease the risk of recurrence. The modalities commonly used for the primary staging of rectal cancer include EUS, computed tomography, and magnetic resonance imaging. EUS may be accompanied by the use of EUS-fine-needle aspiration to provide cytological confirmation. In this review, we take a deeper look into the role of EUS in the accurate staging of rectal cancer, how it compares to other modalities for the same, and how its role has changed in the last decade.
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Endobronchial ultrasound: Echoing in the field of pediatrics p. 371
Can Qin, Bing Wei, Zhuang Ma
DOI:10.4103/eus.eus_40_18  PMID:30289110
Endobronchial ultrasound (EBUS) is a useful technique for the diagnosis and staging of the lung and mediastinal lesions, which is crucial for selecting treatment protocol. Under EBUS guidance, transbronchial needle aspiration (TBNA) is widely applied for obtaining specimens for histological, cytological, and molecular evaluation. Recently, the EBUS scope designed for adults has been used in large pediatric candidates. The presence of lung masses and mediastinal lymphadenopathy in the pediatric population presents a diagnostic challenge; however, EBUS is a promising tool for pediatricians to address these challenging issues. In some centers, the adult EBUS echobronchoscope is applied in transesophageal procedures for pediatric patients. EBUS-guided TBNA can also be used to perform minimally invasive interventional therapy, such as fiducial marker placement for assisting precision radiation, brachytherapy, and radiofrequency ablation therapy. With the development of EBUS equipment designed specifically for children, pediatric EBUS will play an increasingly important role.
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ORIGINAL ARTICLES Top

Safety and efficacy of ultra-tapered mechanical dilator for EUS-guided hepaticogastrostomy and pancreatic duct drainage compared with electrocautery dilator (with video) Highly accessed article p. 376
Mitsuyoshi Honjo, Takao Itoi, Takayoshi Tsuchiya, Reina Tanaka, Ryosuke Tonozuka, Shuntaro Mukai, Atsushi Sofuni, Yuichi Nagakawa, Hidenori Iwasaki, Takanori Kanai
DOI:10.4103/eus.eus_2_18  PMID:29882518
Background and Objectives: Successful tract dilation is one of the most important steps to accomplish EUS-guided drainage. Although mechanical dilation is safer than electrocautery dilation, no dedicated mechanical dilator (MD) is currently available. Thus, we developed a new ultra-tapered MD for EUS-guided drainage. This study aimed to evaluate the safety and usefulness of this novel MD. Patients and Methods: Consecutive patients who underwent EUS-guided hepaticogastrostomy (EUS-HGS) or EUS-guided pancreatic duct drainage (EUS-PD) at two centers were included in the study. Dilation of the needle tract was initially performed with a diathermic sheath or the ultra-tapered MD. Technical success and adverse events were assessed. Results: Sixty-four patients (mean age = 68.9 ± 13.8 years, 35 men) underwent EUS-HGS (49 patients) and EUS-PD (15 patients). Thirty-three patients were included in the cautery dilator (CD) group and 31 in the ultra-tapered MD group. Initial dilation of the puncture site was achieved in 95.3% (61/64): 97% (32/33) of the patients in the CD group and 93.3% (29/31) of the patients in the MD group (P < 0.05). Adverse events were observed in 14 patients: abdominal pain in 8 patients and bleeding in 6 patients at the puncture site. All bleedings occurred in the CD group and there was no patient in whom bleeding occurred after EUS intervention in the MD group (P = 0.04). Conclusion: The novel ultra-tapered MD designed for interventional EUS appears to be safe and useful as it reduced postprocedure bleeding with a high technical success rate compared with the conventional electrocautery dilator.
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Initial experience with EUS-guided microbiopsy forceps in diagnosing pancreatic cystic lesions: A multicenter feasibility study (with video) p. 383
Bojan Kovacevic, John Gásdal Karstensen, Roald Flesland Havre, Khanh Do-Cong Pham, Marc Giovannini, Emanuele Dabizzi, Paolo Arcidiacono, Erwin Santo, Enrique Vazquez Sequeiros, Pia Klausen, Charlotte Vestrup Rift, Jane Preuss Hasselby, Anders Toxværd, Evangelos Kalaitzakis, Carsten Palnæs Hansen, Peter Vilmann
DOI:10.4103/eus.eus_16_18  PMID:30168479
Background and Objectives: Cystic lesions of the pancreas represent a diagnostic dilemma. Recently, a through-the-needle microbiopsy forceps has become available, enabling procurement of EUS-guided histological specimens from the pancreatic cyst wall. The aim of this study was to evaluate the use of this novel instrument in a multicenter clinical setting. Patients and Methods: Patients referred for EUS evaluation of pancreatic cysts and attempted EUS-guided microbiopsy was included retrospectively from six international tertiary centers. Patient's demographics, EUS findings, technical and clinical success, and histopathological results were recorded. Results: A total of 28 patients were identified. We report a technical success rate of 85.7% (n = 24). Biopsies were generally of good quality and contributed to the diagnosis in 20 patients (clinical success of 71.4%). Three adverse events were recorded (10.7%). Conclusions: The use of the microbiopsy forceps is feasible with acceptable rates of technical and clinical success. Prospective studies are warranted to determine the diagnostic potential compared to the other modalities. However, the results from this preliminary study are promising.
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Feasibility and safety of EUS-guided selective portal vein embolization with a coil and cyanoacrylate in a live porcine model p. 389
Tae Young Park, Dong-Wan Seo, Hyeon-Ji Kang, Tae Jun Song, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, Myung-Hwan Kim
DOI:10.4103/eus.eus_18_18  PMID:30246708
Background and Objectives: Preoperative portal vein (PV) embolization using the percutaneous transhepatic approach has been performed in patients with hepatobiliary malignancy before extensive liver resection. The aim of this study is to evaluate the technical feasibility and initial safety of EUS-guided selective PV embolization using a coil and cyanoacrylate in a live porcine model. Methods: EUS-guided selective intrahepatic PV embolization with a coil and cyanoacrylate was performed in 9 pigs. The selected PV was punctured with 19G fine-needle aspiration (FNA) needle, and the coil was inserted under EUS-guidance. The cyanoacrylate was then immediately injected through the same FNA needle. The blood flow change in the embolized PV was evaluated using color Doppler EUS. A necropsy was performed following the 1-week observation period. Results: The success rates for the coil and cyanoacrylate delivery were 88.9% (8/9) and 87.5% (7/8), respectively. In 1 case, the coil migrated into the hepatic parenchyma. In another case, the cyanoacrylate injection failed due to early clogging in the FNA needle. There was a complete blockage of blood flow confirmed by color Doppler EUS in the embolized PV after coil and cyanoacrylate treatment. There was coil migration into the hepatic parenchyma in 1 case. There was no animal distress observed during the 1-week observation period before necropsy. The necropsy showed no evidence of damage to the intra-abdominal organs, and the selected PV was totally occluded with embolus. Conclusion: The study findings indicate EUS-guided selective PV embolization is both technically feasible and initially safe in an animal model.
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Discriminating chronic pancreatitis from pancreatic cancer: Contrast-enhanced EUS and multidetector computed tomography in direct comparison p. 395
Finn-Jörn Harmsen, Dirk Domagk, Christoph F Dietrich, Michael Hocke
DOI:10.4103/eus.eus_24_18  PMID:30246709
Background and Objectives: To compare the ability of multidetector computed tomography (MDCT) and contrast-enhanced EUS to discriminate chronic pancreatitis (CP) from pancreatic ductal adenocarcinoma (PDAC). Subjects and Methods: A total of 215 patients (age: 62 ± 15 years, sex: f/m 80/135) were included in this retrospective study. All patients were examined by conventional endoscopic B-mode and contrast-enhanced high mechanical index EUS (CEHMI-EUS). CELMI-EUS was performed in 159 patients and endoscopic sonoelastography (ESE) in 210 patients. MDCT was carried out in 131 patients as part of their clinical work-up. Radiological reports were retrospectively analyzed. Final diagnosis was achieved by biopsy and evaluation of cytological specimens collected was performed by EUS-FNA, surgery, or follow-up of 12 months or more in patients with benign findings. In a subgroup of 100 patients, all diagnostic five methods were performed, and head-to-head analysis was performed. Results: Sensitivity and specificity for MDCT were 89% and 70% and for CEHMI-EUS were 96% and 91%, respectively. Sensitivities and specificities for EUS were 92% and 63% for B-Mode EUS, 96% and 38% for ESE, and 82% and 76% for CELMI-EUS, respectively. In the head-to-head analysis, each modality had shown lower numbers for specificity than shown in the overall group analysis because of high drop-out rate. EUS-FNA for PDAC had a sensitivity of 96% and a specificity of 100%. Conclusions: Contrast-enhanced EUS is a reliable tool in discriminating PDAC from CP.
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EUS-guided antegrade metal stenting with hepaticoenterostomy using a dedicated plastic stent with a review of the literature (with video) p. 404
Kenjiro Yamamoto, Takao Itoi, Takayoshi Tsuchiya, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjo, Shuntaro Mukai, Mitsuru Fujita, Yasutsugu Asai, Yukitoshi Matsunami, Takashi Kurosawa, Atsushi Sofuni, Yuichi Nagakawa
DOI:10.4103/eus.eus_51_18  PMID:30531024
Background and Objectives: Recently, a novel EUS-guided biliary drainage (EUS-BD) technique consisting of EUS-guided antegrade stenting and EUS-guided hepaticoenterostomy (EUS-AS+HES) using two conventional metal stents (MS) has been reported to decrease adverse events and maintain longer stent patency for malignant biliary obstruction (MBO). However, only a few limited reports have evaluated this technique. Finally, dedicated plastic stents (PSs) have been developed to perform EUS-HES safely. The aim of the present study was to evaluate the outcome in EUS-AS+HES for MBO using the dedicated HES PSs. Methods: The results of a total of 23 patients who underwent EUS-AS+HES (18 simultaneous cases and 5 sequential cases) for MBO from October 2014 to July 2017 were retrospectively reviewed. Results: Technical and clinical success rates were 100% (23/23). Adverse events were seen in 8.7% (2/23); 2 cases of mild biliary peritonitis, which were successfully managed conservatively. Overall survival was 96 days and the median duration of stent patency, including stent dysfunction, patient death, and last follow-up, was 66.0 days (53 days in simultaneous cases and 78 days in sequential cases). Stent dysfunction was seen in 13.0% (3/23) of patients in 267, 263, and 135 days after the procedure. Conclusions: The novel EUS-BD technique, EUS-AS using MS plus HES employing a dedicated PS, was shown to be a feasible procedure for MBO and should yield longer duration of stent patency. Furthermore, sequential antegrade stenting in cases of occluded HES seems to be one other option instead of HES stent exchange. Further large-scale comparison studies with EUS-HES or EUS-AS are required to confirm its clinical efficacy.
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CASE REPORT Top

Initial report of transesophageal EUS-guided intraparenchymal lung mass core biopsy: Findings and outcomes in two cases Highly accessed article p. 413
Douglas G Adler, Moamen Gabr, Linda Jo Taylor, Benjamin Witt, Douglas Pleskow
DOI:10.4103/eus.eus_13_18  PMID:29786035
EUS is most commonly used to evaluate and sample lesions of the abdomen but has only been used on rare occasions to evaluate and sample lung lesions. Prior reported cases of EUS sampling of lung lesions were performed by fine-needle aspiration. We present what is believed to be the first reported cases of EUS-guided core biopsy of intraparenchymal lung lesions through two separate case reports. Both patients had the upper lobe lesions not amenable to bronchoscopy or endobronchial ultrasound, and both patients underwent core biopsy without adverse event. This report of two cases shows that EUS-guided core biopsy of intraparenchymal lung lesions is technically possible and may not necessarily result in adverse events such as hemorrhage, pneumothorax, or infection.
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IMAGES AND VIDEOS Top

EUS-guided gastroenterostomy for afferent loop syndrome treatment stent p. 418
Dina Chaaro Benallal, Solene Hoibian, Fabrice Caillol, Erwan Bories, Christian Presenti, Jean Phillippe Ratone, Marc Giovannini
DOI:10.4103/eus.eus_41_17  PMID:30004036
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EUS-FNA of gastric cancer metastatic to the head of pancreas using a forward oblique viewing echoendoscope in a case with Roux-en-Y anatomy Highly accessed article p. 420
Suguru Mizuno, Yousuke Nakai, Hiroyuki Isayama, Tatsunori Suzuki, Kei Saito, Rie Uchino, Naminatsu Takahara, Hirofumi Kogure, Minoru Tada, Kazuhiko Koike
DOI:10.4103/eus.eus_107_17  PMID:29536952
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LETTER TO EDITOR Top

Single-operator experience with a 20-mm diameter lumen apposing metal stent to treat patients with large pancreatic fluid collections from pancreatic necrosis p. 422
Douglas G Adler
DOI:10.4103/eus.eus_39_18  PMID:30531025
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