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   Table of Contents - Current issue
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May-June 2020
Volume 9 | Issue 3
Page Nos. 147-207

Online since Saturday, June 13, 2020

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EDITORIAL  

EUS in the evaluation of metastatic lesions to the pancreas p. 147
Hussein Hassan Okasha, Katarzyna M Pawlak, Michał Żorniak, Anna Wiechowska-Kozłowska, Yehia Mazen Naga, Ramy ElHusseiny
DOI:10.4103/eus.eus_31_20  
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COMMENTARY Top

Evolution and a promising role of EUS-FNA in gene and future analyses p. 151
Masaki Kuwatani, Naoya Sakamoto
DOI:10.4103/eus.eus_29_20  
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GUIDELINE Top

A proposal for the ideal algorithm for the diagnosis, staging, and treatment of pancreas masses suspicious for pancreatic adenocarcinoma: Results of a working group of the Canadian Society for Endoscopic Ultrasound p. 154
Naveen Arya, Jonathan M Wyse, Shiva Jayaraman, Chad G Ball, Eric Lam, Sarto C Paquin, Peter Lightfoot, Anand V Sahai
DOI:10.4103/eus.eus_28_20  
Numerous clinical pathways exist for patients presenting with a suspicious pancreatic mass. These range from direct surgical intervention following staging, with preoperative cross-sectional imaging, EUS with or without fine-needle aspiration or fine-needle core biopsy; neoadjuvant chemotherapy and/or radiation therapy; or palliation. Although international guidelines exist for pancreas cancer management, the ideal workup and treatment for a suspicious pancreas mass is unclear. During its annual meeting in September 2017 (The Forum for Canadian Endoscopic Ultrasonography), the Canadian Society of Endoscopic Ultrasound organized a working group of experienced endosonographers and hepatobiliary surgeons from across Canada to achieve this goal.
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REVIEW ARTICLES Top

How to perform EUS-based cholecystolithotomy p. 162
Nan Ge, Kai Zhang, Jinlong Hu, Siyu Sun
DOI:10.4103/eus.eus_36_20  
EUS-guided gallbladder drainage (EUS-GBD) is gradually emerging as an option for patients with cholecystitis. A stent-bridged endoscopic intervention in the gallbladder (GB) has been proposed. The formation of a fistulous tract after EUS-GBD facilitates the entry of the endoscope inside the GB to perform endoscopic lithotomy and polypectomy, which is an efficient and safe procedure. However, the technical aspects of this procedure in order to optimize the success rate have only been scarcely discussed. This paper discusses the EUS-GBD prepared for per-oral cholecystolithotomy, the stent indwelling time, the procedure, the devices of per-oral cholecystolithotomy and the follow-up. The recently published literature on this topic is also updated in this review.
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Comparison between 22G aspiration and 22G biopsy needles for EUS-guided sampling of pancreatic lesions: A meta-analysis Highly accessed article p. 167
Antonio Facciorusso, Harshvardhan Singh Bajwa, Kavitha Menon, Vincenzo Rosario Buccino, Nicola Muscatiello
DOI:10.4103/eus.eus_4_19  PMID:31031330
Background and Objective: Robust data in favor of clear superiority of 22G fine-needle biopsy (FNB) over 22G FNA for an echoendoscopic-guided sampling of pancreatic masses are lacking. The objective of this study is to compare the diagnostic outcomes and sample adequacy of these two needles. Materials and Methods: Computerized bibliographic search on the main databases was performed and restricted to only randomized controlled trials. Summary estimates were expressed regarding risk ratio (RR) and 95% confidence interval. Results: A total of 11 trials with 833 patients were analyzed. The two needles resulted comparable in terms of diagnostic accuracy (RR 1.02, 0.97–1.08; P = 0.46), sample adequacy (RR 1.01, 0.96–1.06; P = 0.61), and histological core procurement (RR 1.01, 0.89–1.15; P = 0.86). Pooled sensitivity in the diagnosis of pancreatic cancer was 93.1% (87.9%–98.4%) and 90.4% (86.3%–94.5%) with biopsy and aspirate, respectively, whereas specificity for detecting pancreatic cancer was 100% with both needles. Analysis of the number of needle passes showed a nonsignificantly positive trend in favor of FNB (mean difference: −0.32, −0.66–0.02; P = 0.07). Conclusion: Our meta-analysis stands for a nonsuperiority of 22G FNB over 22G FNA; hence, no definitive recommendations on the use of a particular device can be made.
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ORIGINAL ARTICLES Top

EUS-guided pancreatic drainage: A steep learning curve p. 175
Amy Tyberg, Vimal Bodiwala, Prashant Kedia, Paul R Tarnasky, Muhammad Ali Khan, Aleksey Novikov, Monica Gaidhane, Jose Celso Ardengh, Michel Kahaleh
DOI:10.4103/eus.eus_3_20  
Background and Objective: EUS-guided pancreatic drainage (EUS-PD) is an efficacious, acceptable risk option for patients with pancreatic duct obstruction who fail conventional ERCP. The aim of this study was to define the learning curve (LC) for EUS-PD. Methods: Consecutive patients undergoing EUS-PD by a single operator were included from a dedicated registry. Demographics, procedural info, adverse events, and follow-up data were collected. Nonlinear regression and cumulative sum (CUSUM) analyses were conducted for the LC. Results: Fifty-six patients were included (54% of male, with a mean age of 58 years). Technical success was achieved in 47 patients (84%). Stent placement was antegrade in 36 patients (77%) and retrograde in 11 (23%). Clinical success was achieved in 46/47 (98%) patients who achieved technical success. Adverse events were seen in 13 patients (6 of whom did not achieve technical success) and included bleeding requiring embolization (n = 5), bleeding treated with clips peri-procedurally (n = 1), pancreatitis (n = 5), and a pancreatic fluid collection drained via EUS-drainage (n = 2). The median procedural time was 80 min (range 49–159 min). The CUSUM chart showed that 80-min procedural time was achieved at the 27th procedure. Durations further reduced 40th procedure onward, reaching a plateau indicating proficiency (nonlinear regression P < 0.0001). Conclusion: Endoscopists experienced in EUS-PD are expected to achieve a reduction in procedural time over successive cases, with efficiency reached at 80 min and a learning rate of 27 cases. Continued improvement is demonstrated with additional experience, with plateau indicating mastery suggested at the 40th case. EUS-PD is probably one of the hardest therapeutic endosonographic procedures to learn.
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Appraisal of EUS-guided needle-based confocal laser endomicroscopy in the diagnosis of pancreatic lesions: A single Chinese center experience p. 180
Sijie Hao, Weiqun Ding, Yuqin Jin, Yang Di, Feng Yang, Hang He, Hengchao Li, Chen Jin, Deliang Fu, Liang Zhong
DOI:10.4103/eus.eus_9_20  
Background and Objectives: In the recent years, EUS is one of the routine procedures in the diagnosis of pancreatic diseases. EUS-guided needle-based confocal laser endomicroscopy (nCLE) is a novel minimally invasive imaging technique in diagnosis of pancreatic diseases. The pilot researches provided us some preliminary findings and conclusions with small samples, low rate of pathological correspondence. The aim of this current study was to evaluate the diagnostic efficacy of EUS-guided nCLE in solid pancreatic lesions (SPLs) and pancreatic cystic lesions (PCLs) based on large samples. The date was obtained on nCLE imaging findings and high rate of correlation with pathology. Material and Methods: Patients enrolled in the study were underwent EUS-nCLE to achieve the nCLE images and diagnosis. Comparing with the final diagnosis, including surgical histopathological results or cyto-/histopathology through FNA, the efficacy and accuracy of nCLE in diagnosis in solid and cystic pancreatic lesions were evaluated. In other cases, clinical diagnoses were achieved based on the combination with clinical history, image findings and fluid analysis and cytology, by 3 independent committee members strongly agreed with a concordant diagnosis. Results: Totally 172 patients were enrolled into the study. The overall rate of final diagnosis was about 65% while 50% in cystic lesion. The mean sensitivity, specificity, negative predictive value, positive predictive value and accuracy of the nCLE in diagnosis of PDAC is 90.3%, 89.5%, 93.3%, 85.0% and 90.0% respectively. The efficacy and accuracy of pancreatic cystic lesions were very satisfying and some additional nCLE signs were found, including “black aggregates of cells, forming as gland-like structure, surrounding by fibro and vessels” in neuroendocrine tumors (NETs); “black columnar protrusions near vascular area” in the pseudopapillary solid tumor (SPT); macrophage in tuberculosis (TB) and small aggregate of black regular cells maybe corresponds to ovarian-like stroma in mucinous cystadenoma (MCN). In the study, 20 (11.6%) patients suffered complications, including symptomatic (5.2%) and asymptomatic (6.4%). Conclusions: nCLE observation could improve characterization of indeterminate cysts, or confirm the EUS impression, when cytological confirmation is missing. The technique may deliver information to better guide our clinical decisions.
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Diagnostic efficacy of white core cutoff lengths obtained by EUS-guided fine-needle biopsy using a novel 22G franseen biopsy needle and sample isolation processing by stereomicroscopy for subepithelial lesions p. 187
Kosuke Okuwaki, Hironori Masutani, Mitsuhiro Kida, Hiroshi Yamauchi, Tomohisa Iwai, Eiji Miyata, Rikiya Hasegawa, Toru Kaneko, Hiroshi Imaizumi, Masafumi Watanabe, Takahiro Kurosu, Masayoshi Tadehara, Kai Adachi, Akihiro Tamaki, Wasaburo Koizumi
DOI:10.4103/eus.eus_18_20  
Objectives: The aim of this study is to estimate the cutoff length for stereomicroscopically visible white core (SVWC) required for the pathological diagnosis of subepithelial lesions (SELs) from samples obtained using a novel 22-G Franseen biopsy needle and determine the sensitivity using the SVWC cutoff length. Patients and Methods: Thirty patients with SELs requiring pathological diagnoses were included. EUS-guided fine-needle biopsies (EUS-FNBs) were performed using a novel 22G Franseen biopsy needle. SVWC cutoff lengths were measured using sample isolation processing by stereomicroscopy (SIPS). The utility of the calculated SVWC cutoff lengths was measured. Results: The procedural success and SVWC sampling rates were both 100%. The median SVWC length was 14.5 mm. Pathological examinations identified 16 patients with gastrointestinal stromal tumors, 7 with schwannomas, 6 with leiomyomas, and 1 with an ectopic pancreas. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosing malignancy using EUS-FNB were all 100%. The final diagnostic accuracy was 100%. Regarding the final diagnosis, based on the receiver operating characteristic curves calculated using the SVWC length, the area under the curve was 0.958 (95% confidence interval: 0.897–1.020, P < 0.001) and the cutoff length was 4 mm. The sensitivity of the new SVWC cutoff length was 98.7%. Conclusions: Diagnostic results of EUS-FNBs using a novel 22-G Franseen biopsy needle were significantly better with SVWC cutoff lengths ≥4 mm. Performing the SIPS procedure with a cutoff value of 4 mm as an index may be especially useful for successful pathological diagnosis of SELs at institutions where rapid on-site evaluation cannot be performed.
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Development of a new risk score for invasive cancer in branch-duct intraductal papillary mucinous neoplasms according to morphological characterization by EUS p. 193
Laura Uribarri-Gonzalez, Enrique Pérez-Cuadrado-Robles, Soraya López-López, José Lariño-Noia, Emma Martínez-Moneo, Julio Iglesias-García, Ignacio Fernández-Urién-Sanz, Juan Vila-Costas
DOI:10.4103/eus.eus_11_20  
Background and Objective: The management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is determined by a number of guidelines. The current weight of risk factors by EUS predicting invasive cancer is unknown. The aim of this study is to develop a risk score for early prediction of invasive cancer according to morphological characterization by EUS in a surgical cohort. Materials and Methods: This is an observational, multicenter retrospective study. All consecutive patients with a histologically proven BD-IPMN who underwent previous EUS between 2005 and 2017 were included. Morphological features by EUS were evaluated. A score using a logistic regression model was performed to assess the risk of invasive cancer. Results: Of 335 patients who underwent pancreatic surgery, 131 (median age: 66 years, 50.4% – male) were included. By multivariable analysis, lymph nodes (odds ratio [OR]: 17.7 [confidence interval (CI) 95%: 2.8–112.6], P = 0.002, 4 points), main pancreatic duct ≥10 mm (OR: 8.6 [CI 95%: 1.9–39.5], P = 0.006, 2 points), abrupt change of pancreatic duct (OR: 5.5 [CI 95%: 1.4–22.2], P = 0.016, 1.5 points), and solid component (OR: 4.2 [CI 95%: 1.3–13.6], P = 0.017, 1 point) were independent factors associated with invasive cancer and included in the model. The following categories of the score (0–8.5 points) – A (0–1), B (1.5–3), C (3.5–5), and D (5.5–8.5 points) – presented a positive predictive value of 8.5%, 38.9%, 62.5%, and 100%, respectively. The area under the curve was 0.857 (P < 0.001), with an overall sensitivity and specificity of 84% and 70% in the internal validation of the score. Conclusion: This EUS predictive score for invasive cancer in BD-IPMN has a high accuracy and could be an additional tool to consider in patient management.
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IMAGES AND VIDEOS Top

EUS-aided diagnosis and treatment of bleeding gastric Dieulafoy's lesion (with video) p. 200
Biggs Saravanan Ramachandran, Blessy Abraham, Anoop C Haridas, Premalatha Narayanan
DOI:10.4103/eus.eus_7_20  
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The role of EUS in missed and known linitis plastica p. 202
Harshit S Khara, Dana M Stewart, Bradley D Confer, David L Diehl, Amitpal S Johal
DOI:10.4103/eus.eus_20_18  
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Dysphagia caused by a rare esophageal external compression lesion (with video) p. 205
Chenyue Tang, Jianwei Zhu, Duanmin Hu, Guilian Chen
DOI:10.4103/eus.eus_26_20  
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ERRATUM Top

Erratum: A prospective comparison of conventional cytology and digital image analysis for the identification of pancreatic malignancy in patients undergoing EUS-FNA p. 207

DOI:10.4103/2303-9027.282542  
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